# data[].attributes.body
https://pubmed.ncbi.nlm.nih.gov/30602194/

# data[].attributes.attachment_link.readable_text
Affiliations

¹ Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

² Krieger School of Arts and Sciences, The Johns Hopkins University, Baltimore, Maryland.

³ Division of Adult Reconstruction, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

Affiliations

¹ Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

² Krieger School of Arts and Sciences, The Johns Hopkins University, Baltimore, Maryland.

³ Division of Adult Reconstruction, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland.

Abstract

The ability to kneel is one of the many patient goals after total knee arthroplasty (TKA). Few studies have addressed patients' ability to kneel after TKA as a primary outcome. Given the altered biomechanics of the knee after TKA, the various implant designs, and multiple surgical approaches, there is a need to further understand the patient's kneeling ability after TKA. We evaluated the available literature on this topic to help to guide postoperative care recommendations. Biomechanical data show that the load borne by the patellofemoral joint is elevated significantly at all flexion angles, whereas tibiofemoral articulation pressures are elevated only at 90 to 120 degrees of flexion. However, these increased pressures are rarely borne by prosthetic knees because patients often avoid kneeling after TKA. In patients who do kneel after surgery, data show that increased range of motion promotes improved kneeling performance. Targeted interventions to encourage kneeling after TKA, including preoperative education, have not shown an ability to increase the frequency with which patients kneel after TKA. Reasons for patient avoidance of kneeling are multifaceted and complex. There is no biomechanical or clinical evidence contraindicating kneeling after TKA. There are insufficient data to recommend particular prosthetic designs or surgical approaches to maximize kneeling ability after surgery. Musculoskeletal health care providers should continue to promote kneeling to allow patients to achieve maximum clinical benefit after TKA.

Conflict of interest statement

Similar articles

Biomechanics of hyperflexion and kneeling before and after total knee arthroplasty.

Lee TQ. Lee TQ. Clin Orthop Surg. 2014 Jun;6(2):117-26. doi: 10.4055/cios.2014.6.2.117. Epub 2014 May 16. Clin Orthop Surg. 2014. PMID: 24900891 Free PMC article. Review.

The ability to kneel before and after total knee arthroplasty : the role of the pattern of osteoarthritis and the position of the femoral component.

Scott CEH, Holland G, Gillespie M, Keenan OJ, Gherman A, MacDonald DJ, Simpson AHRW, Clement ND. Scott CEH, et al. Bone Joint J. 2021 Sep;103-B(9):1514-1525. doi: 10.1302/0301-620X.103B9.BJJ-2020-2129.R2. Bone Joint J. 2021. PMID: 34465156

Factors preventing kneeling in a group of pre-educated patients post total knee arthroplasty.

White L, Stockwell T, Hartnell N, Hennessy M, Mullan J. White L, et al. J Orthop Traumatol. 2016 Dec;17(4):333-338. doi: 10.1007/s10195-016-0411-1. Epub 2016 May 27. J Orthop Traumatol. 2016. PMID: 27234004 Free PMC article.

Can knees kneel? Kneeling ability after total, unicompartmental and patellofemoral knee arthroplasty.

Hassaballa MA, Porteous AJ, Newman JH, Rogers CA. Hassaballa MA, et al. Knee. 2003 Jun;10(2):155-60. doi: 10.1016/s0968-0160(02)00148-5. Knee. 2003. PMID: 12787999

Optimizing flexion after total knee arthroplasty: advances in prosthetic design.

Sultan PG, Most E, Schule S, Li G, Rubash HE. Sultan PG, et al. Clin Orthop Relat Res. 2003 Nov;(416):167-73. doi: 10.1097/01.blo.0000081937.75404.ee. Clin Orthop Relat Res. 2003. PMID: 14646757 Review.

The kneeling test is a valid method of assessing kneeling tolerance.

Calvert ND, Smith A, Kuster L, Calvert M, Ebert J, Ackland T, Kuster MS. Calvert ND, et al. Knee Surg Sports Traumatol Arthrosc. 2019 Nov;27(11):3705-3712. doi: 10.1007/s00167-019-05505-3. Epub 2019 Apr 9. Knee Surg Sports Traumatol Arthrosc. 2019. PMID: 30968237

# data[].attributes.attachment_link.keywords[]
national center for biotechnology information

# data[].attributes.attachment_link.title
Kneeling after Total Knee Arthroplasty - PubMed

# data[].attributes.attachment_link.description
The ability to kneel is one of the many patient goals after total knee arthroplasty (TKA). Few studies have addressed patients' ability to kneel after TKA as a primary outcome. Given the altered biomechanics of the knee after TKA, the various implant designs, and multiple surgical approaches, there ...

# data[].attributes.body
Good evidence for using NMES after TKA, I'm thinking of our people with poor quad activation...

https://pubmed.ncbi.nlm.nih.gov/14964588/

# data[].attributes.body
JOSPT 2021

# data[].attributes.headline
Parkinson's CPG- CSM has a course on this

# data[].attributes.subject
Parkinson's CPG- CSM has a course on this

# data[].attributes.attachment_link.readable_text
Whatever your profession, you need a great hobby to get you out of the clinic or house and take your mind off the daily grind.

There are many ways to care for yourself such as yoga, having enough sleep, a balanced diet, and even engaging in sports can do you better. There are many sports to choose from, but golf is always a winner! It's played in a beautiful setting, requires some strategic gameplay, and allows for some exercise too (unless you feel like taking the golf cart).

There are a few other reasons that it's the perfect sport for PTs specifically. If you're already active, it's worth adding a round or two of golf to your exercise routine for its health benefits and enjoyment.

Here are our thoughts on why physical therapists should play golf!

It's Low Impact

As PTs, we understand that protecting the joints is highly important. We see sports injuries all the time, and know the effect that high-impact sports can have.

Naturally, when it comes to playing sports, most PTs are going to be looking for one that goes easy on the joints.

Golf is exactly that. While it's still important to get your swing form right to minimize the risk of injury, there's little to no jarring impact like you have in sports such as rugby, cricket, or tennis.

As PTs, we want to take our own advice when it comes to protecting our bodies! We know the consequences later in life if we don't take precautions, and golf is the perfect way to get in some great exercise that's safe for the joints too.

It Reduces Stress

The combination of low-impact exercise and being out in the great outdoors has some great stress-reduction benefits.

While being a PT is not necessarily the most stressful job in the world, it does bring with it a certain amount of stress, as with any job.

Even light physical exercise burns calories and can help you maintain a healthy weight. When you add the extra element of being outdoors, you can expect benefits such as:

Better quality sleep

Lowered blood pressure

Lowered cholesterol

As well as physical benefits, nature and exercise can boost mental health! Research indicates that job-related anxiety and depression diminishes with outdoor exercise.

When you're working a stressful job in an enclosed clinic, getting out on the golf course can be a super way to take the edge off, relax, and let the stresses of the day melt away.

It's a Great Social Distancing Hobby

PTs spend all day getting up close and personal with their clients. There's no way to do physical therapy without getting close!

In today's COVID-19 world, the constant need for sanitization, wearing a mask, and being extra careful can add to the stress and exhaustion of daily life.

Being out on the golf course is the perfect way to get away from it all. If you're playing alone, you can even remove your mask and breathe in the fresh air without worrying.

Even if you're playing with friends, it's easy to socially distance yourself and stay safe on the course.

Conclusion

PTs, if you're looking for something different to add to your exercise routine, why not try golf? Not only is it low-impact, stress-relieving, and great for socially distancing, but it's also suitable for players of all levels, alone or in a group, and offers both physical and mental benefits.

# data[].attributes.attachment_link.title
Why Physical Therapists Should Play Golf * Posts by EIM | Evidence In Motion

# data[].attributes.attachment_link.description
Whatever your profession, you need a great hobby to get you out of the clinic or house and take your mind off the daily grind. There are many ways to care for yourself such as yoga, having enough sleep, a balanced diet, and even engaging in sports can do you better.

# data[].attributes.attachment_link.readable_text
Well, it's finally here. On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) released the hotly anticipated 2021 final rule, and eager compliance experts wasted no time digging through its contents. But their digging unearthed legislative changes that are, to put it lightly, less than ideal for rehab therapists. This year's final rule is not for the faint of heart-though there are some golden nuggets buried within. So, without further ado, here's how the 2021 final rule affects PTs, OTs, and SLPs.

The 9% cut is here to stay.

Let's get the biggest bombshell out of the way: CMS is moving forward with the payment increases to evaluation and management (E/M) services, and to pay for those increases, it will cut the conversion factor (i.e., the number that determines all CPT code payments) from $36.0986 to $32.4085. Ultimately, this means the 9% cut to PT, OT, and SLP services is officially happening.

When asked about these payment changes during a press call, CMS Administrator Seema Verma said, "Primary care providers are not being reimbursed appropriately for the time that they are spending with patients, and so we can't continue to penalize those providers while continuing to have increases for providers that are doing more procedures. At the end of the day, we are reimbursing all providers for the time that they spend with patients." While many affected providers have pleaded with CMS to reconsider these cuts in light of pandemic-related financial troubles, according to the above-linked article, Verma also said that "the problems providers face from COVID-19 have already been handled."

Congressional Intervention

PTs, OTs, and SLPs are less than one month away from one of the most significant industry-wide payment cuts in recent history. However, even though rehab therapists are entering the eleventh hour, they still have time to make one final move: harness the power of Congress. So, contact your federal representatives and ask them to support H.R. 8702-a bill that will temporarily increase Medicare payments for providers who are slated to receive cuts next year. (And have your patients contact Congress, too!)

PT, OT, and SLP evaluation codes will have slightly higher reimbursement rates.

The 9% cuts pose a substantial blow to the PT, OT, and SLP industries-but they do come with one small silver lining. CMS has acknowledged that PT, OT, and SLP evaluations "inherently include work associated with assessment and work associated with management, similar to the work included in the office/outpatient E/M visits, which involve time spent face-to-face assessing and treating the patient."

Because therapy evaluations are so similar to E/M codes, CMS has decided that they also deserve a small payment bump. So, beginning in 2021, therapists can expect to see slightly higher payments for codes 97161-97168 and 92521-92524.

Before you get too excited, keep in mind that these payment increases will not offset the 9% cut. In fact, the 9% calculation actually accounted for those increases-but they did little to influence the net negative impact of the conversion factor reduction. Plus, CMS has admitted that "therapy evaluation services do not account for a large portion of allowed charges for these specialties."

PTs, OTs, and SLPs will not be allowed to provide and bill for telehealth services beyond the COVID-19 public health emergency.

In the 2021 final rule, CMS plainly stated that once the public health emergency ends, Administrator Seema Verma will lose the temporary permissions that allowed her to give PTs, OTs, and SLPs the freedom to independently bill for telehealth. In other words, after the pandemic, rehab therapists will not be allowed to bill for telehealth-unless it's billed incident-to a physician.

As for telehealth codes, CMS finalized its proposal to put 16 PT and OT codes and five SLP codes on a temporary telehealth list in an effort to give clinicians "the opportunity to conduct the kinds of review or develop the kind of evidence we usually consider when adding services to the Medicare telehealth services list on a permanent basis." CMS also encouraged providers who bill these codes (and their patients) to provide feedback about their efficacy.

"Feedback from patients and clinicians is essential to helping CMS understand how the use of telehealth services may have contributed positively to, or negatively affected, the quality of care provided to beneficiaries during the PHE for COVID-19, enabling us to better determine which services should be retained on the Medicare telehealth services list until we can give them full consideration under our established rulemaking process."

Supervision

To help providers who bill telehealth incident-to another provider (e.g., therapists to physicians), CMS finalized its proposal to amend the definition of direct supervision. This will allow supervision to occur virtually through real-time audio and video technology, "expand[ing] access to needed care in communities that may not have a supervising physician on site."

Other Remote Services

E-Visits

CMS will allow PTs, OTs, and SLPs to bill e-visit codes on a permanent basis. These codes are also now "sometimes therapy" codes-meaning they must be billed with a GP, GO, or GN modifier when billed by a PT, OT, or SLP, respectively. That said, CMS later noted, "After consideration of the comments received, we are finalizing our proposal to replace G2061-G2063 with CPT codes 98970-98972." So, when billing for e-visits, PTs, OTs, and SLPs must use one of those CPT codes instead of the G-codes.

Additionally, CMS created two new virtual care codes that are available to rehab therapists:

G2250: "Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment."

G2251: "Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion."

These new codes are valued the same as the codes for virtual check-ins.

Telephone Visits

CMS also made a decision regarding payment for telephone visits. After the conclusion of the COVID-19 PHE, CMS will no longer pay for telephone visit CPT codes 98966, 98967, and 98968.

Therapy assistants can provide maintenance therapy.

Back in May, to assist with the strain of the pandemic, CMS temporarily amended its policies to allow outpatient PTAs, OTAs, and COTAs to provide maintenance therapy. After receiving an overwhelmingly positive response to this change (and realizing it could "create greater conformity" between the standards of inpatient and outpatient therapy), CMS decided to make the change permanent.

So, from here on out, PTs and OTs can "delegate maintenance therapy services to therapy assistants on a permanent basis as clinically appropriate."

Therapy students can assist with documentation.

This isn't a change to current regulations, but rather a clarification made by CMS. According to the government agency, therapy students can document a session, and therapy providers simply have to "review and verify (sign and date), rather than re-document" the notes. This allowance helps ensure therapists "are able to spend more time furnishing therapy services, including pain management therapies to patients that may minimize the use of opioids and other medications."

PTs and OTs cannot bill remote physiologic monitoring codes.

Again, this is not so much a regulatory change as it is a clarification. CMS has reiterated that remote physiologic monitoring codes -specifically 99453, 99454, 99091, 99457, and 99458-are listed under the evaluation and management (E/M) section of the CPT manual. As such, PTs and OTs cannot bill or receive payment for them.

The therapy threshold is rising slightly.

In a post-final rule release, CMS announced its intention to raise the therapy threshold for 2021. Next year, the annual therapy threshold will be $2,110.00 for PT and SLP services combined, and a separate $2,110 for OT services.

There are some minor tweaks to the MIPS program.

MIPS Value Pathways

MIPS Value Pathways (MVPs), originally intended to take effect in 2021, are "are a subset of measures and activities, established through rulemaking, that can be used to meet MIPS reporting requirements."

Because of the COVID-19 pandemic, CMS is pushing out MVP implementation to 2022 and using that time to hash out the measures' guiding principles and collaborative development criteria. Specifically, in the rule, CMS said, "We are open to considering candidate MVPs that are created utilizing the MVP development criteria, for specialties including physical and occupational therapy."

Extreme and Uncontrollable Circumstances Application

Earlier this year, CMS published changes to the Extreme and Uncontrollable Circumstances Application, thus allowing clinicians to request MIPS category reweighting due to, well, extreme and uncontrollable circumstances. These changes:

Allowed clinicians to request reweighting for any of the performance categories;

Extended the application's submission deadline for those who were affected by the PHE; and

Prevented approved applications from losing their category reweighting by having already submitted data during the performance period.

In the 2021 rule, CMS finalized its proposal to retain those changes-with one exception: "If a clinician, group, or virtual group decides to submit data for the 2021 performance period, the data submission will override the application, and the clinician, group, or virtual group will be scored on the data submitted." So, if your application is approved, don't submit any data in 2021 unless you truly want to be scored.

Low-Volume Threshold

CMS did not propose or finalize any changes to the low-volume threshold. Essentially, that means a large majority of PTs, OTs, and SLPs will not be mandated to participate in MIPS next year.

Performance Threshold and Category Weighting

In 2021, the MIPS neutral payment performance threshold will remain at 60 points, as finalized in the 2020 calendar year rule.

Additionally, CMS finalized its proposal to continue reweighting the promoting interoperability and cost category for PTs, OTs, and SLPs. So, if rehab therapists participate in MIPS in 2021, they will only need to complete the quality and improvement activity categories

Quality Measures

CMS implemented a whole heap of changes to the quality measures that apply to PTs, OTs, and SLPs. Our experts will spend the next few weeks analyzing these changes, but for now, here are the biggest takeaways.

CMS added the following measures to the PT and OT specialty set:

283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

Furthermore, CMS removed the following measure from the PT and OT specialty set:

282: Dementia: Functional Status Assessment

CMS also added the following measure to the speech-language pathology measure set:

134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

All in all, the 2021 final rule contained a lot of bad news for PTs, OTs, and SLPs-but rehab therapists still have a chance to make the most of the situation and petition for change. Have questions about the rule-or any other CMS regulations? Drop 'em in the comment section below.

# data[].attributes.attachment_link.title
What the 2021 Final Rule Means for PTs, OTs, and SLPs | WebPT

# data[].attributes.attachment_link.description
Well, it's finally here. On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) released the hotly anticipated 2021 final rule, and eager compliance experts wasted no time digging through its contents. But their digging unearthed legislative changes that are, to put it lightly, less than ideal for rehab therapists.

# data[].attributes.attachment_link.readable_text
Meredith Castin, PT, DPT, was tired of "being expected to be 3 places at 1 time," then having multiple parties express frustration with her when she failed to do the physically impossible.

There also was the psychological toll of constantly being outed in what therapy staff called "the log of shame"-a ledger in which they were required to list their billable units at the end of each day. If they hadn't met the hospital's productivity requirements, they had to explain why they'd failed to do so. Housed in the charting alcove, the log was readily accessible to every physical therapist (PT), occupational therapist, and physical therapist assistant (PTA)-who thus could see which individuals were making the performance grade and which weren't.

Never mind that the southern California PT's productivity was compromised by multiple factors outside her control, such as being scheduled to work in different units simultaneously, having insufficient time to document, needing to remember ever-changing entry codes on doors, and having constantly to walk back and forth among units.

"I couldn't help but feel inadequate when, for the 10th day in a row, I had to slink to the log to try to justify my 'subpar' productivity," Castin recalls.

She'd earned her PT license at 31, having found an earlier career as a web designer isolating and wanting to make a bigger difference in people's lives. But now, just a few years later, she was wondering if she'd made the right choice.

Similarly, a few years ago Sean Hagey found himself working 60-plus hours a week as a home health PTA in the Kansas City area. His patient load of up to 12 visits per day might have been barely manageable-even though he also was driving 100-plus miles per day-if not for the documentation demands.

"Documentation requirements for EMR [electronic medical records] vary by employer," Hagey observes, "but this particular agency's documentation system was very involved. The form was multiple pages long and required a lot of typing. To do it right, you couldn't cut corners. But that meant that I typically was documenting at home for a couple of hours each night."

Things finally got to the point that Hagey felt "completely fried."

Stressed, exhausted, and concerned that he might begin to feel "compassion fatigue" toward his patients, he started seeing a mental health counselor. At the same time, he often was feeling less than fully present in his work. "If a patient tells you his blood sugar was really high last night, but your brain is in a different spot because you're thinking 'I've got to get caught up on this note' or 'I need to call that person,' you might not properly follow up," he observes.

Hagey, like Castin, felt that something in his work life had to give. The PT and the PTA addressed their situations in different ways.

Castin first shifted from patient care to health care writing. She then created a resource for people in the therapy professions seeking to leverage their degree without facing untenable productivity requirements, documentation demands, and other problematic elements of patient care. That website, The Non-Clinical PT, started simply as an information resource but has become, to Castin's surprise, an online business as well.

Hagey, on the other hand, decided he needed to have a "hard discussion" with his employer. "I told the agency, 'I just can't maintain this pace,'" he says. The PTA outlined the reasons he felt it would be best for him and his patients that his schedule be restructured. He was prepared to seek other employment should his appeal go nowhere.

The agency hardly lauded him for his candor. "They weren't happy about having the discussion," Hagey says. "Still, they did agree to reduce my workload-I think because they made the calculation that it was better for them to keep me than to let me walk, even if I was going to be 'less productive' than they would have preferred." The agency also switched EMR vendors, he notes, which "helped reduce the amount of time spent on documentation, because the previous EMR system had been redundant and was not at all user-friendly."

The changes reduced Hagey's stress level and made his job manageable, although he "still felt pressure to take on additional patients," he says, and sensed resentment from some of the agency's administrators.

"It's been my experience, having worked in the outpatient, skilled care, and home health settings, that some companies and agencies place a high value on patient care, achieving good clinical results, and promoting a healthy work culture," Hagey says, "while other employers seem only to care about the bottom line-making a profit. "I have been fortunate," he adds, "to have worked for some outstanding employers along the way."

While both Castin and Hagey pushed past bleak moments to come out on the other side, they feel that they narrowly dodged a bullet that, they say, continues to claim far too many of their colleagues. That projectile's name is burnout.

'Rampant and Getting Worse'

The extent and causes of burnout among PTs and PTAs has been the subject of scant study. It's widely acknowledged, however-both anecdotally and by APTA-as an area of concern for the profession. (For more on the studies, and on association efforts, see "Ripe for Additional Research" and "APTA Tackles Burnout" on pages 31 and 36, respectively.)

Castin goes so far as to say that burnout in physical therapy is "rampant and getting worse." She bases that statement not only on increasing interest in her website from PTs and PTAs (as well as from those in occupational therapy and speech-language pathology) who express disaffection with clinical practice, but also on popularity of a blogpost ¹ she wrote for a former employer, CovalentCareers.

Type the words "physical therapy burnout" into any search engine and you're likely to quickly encounter a piece with the provocative title "Physical Therapy Burnout is Destroying Our Profession." Posted in October 2017, Castin's piece attracted nearly a half-million views in its first 12 months online, and it has brought her communication from scores of clinicians who say they see themselves-and little hyperbole-in the headline.

Dotted with pseudonyms to protect the identities of the therapists she profiled, Castin's nearly 9,000-word essay kicked off with the story of one of her PT school classmates, who'd been working 2 jobs and logging 40-plus hours per week for over 7 years in order to repay her student loans. "She was always tired but saw no end in sight," Castin wrote.

The post didn't get cheerier from there. Subsequent subheads read "Set Up to Fail," "You Are Only As Good as Your Productivity Levels," "A Thankless Job," and "Nowhere to Grow." While emphasizing that "the highs of physical therapy are higher than any I will ever feel in another job in my life," Castin added, "the joy is being taken out [of clinical practice] on so many levels."

Her essay offered a number of suggestions for addressing and mitigating burnout's causes, and quoted advice from PT experts in areas such as financial planning, fair-pay research, clinical mentorship, and mastering work-life balance. Still, the piece ended only with Castin's modest hope that her words would, at the very least, console burned-out PTs that "they are not alone."

Justin Berry, PT, DPT, PhD, is among the rare individuals who has formally studied burnout in physical therapy. (Again, see "Ripe for Additional Research.") He calls it "a serious issue, due to factors such as productivity requirements, documentation demands, the pressures of student loan debt, reimbursement challenges, and salaries that aren't rising commensurate to the financial demands on PTs." Not only do his studies show that burnout is real, but Berry, like Castin, has been a magnet for disaffected PTs and PTAs due to his association with the issue.

"A number of PTs and PTAs who've seen my name on studies have thanked me for highlighting this subject, and they've shared their personal burnout stories with me-typically centering on productivity challenges and the burden of student debt," says Berry, who directs the PTA program at Northland Community & Technical College in East Grand Forks, Minnesota.

While Hagey deems burnout a "huge" problem across the profession, he emphasizes that along with universal causes such as "productivity metrics," some sources of burnout are more PT- or PTA-centric.

"Obviously, PTAs aren't carrying the debt load from education that most PTs are," he notes. "On the other hand, though, in some clinics PTAs are treated like glorified techs and made to feel that their input isn't welcome. That," he says, "is a recipe for demoralization and burnout."

Drivers of Burnout

"The number-one issue related to burnout that I hear from the PTs who contact me is unrealistic productivity requirements, which have 2 devastating effects on clinicians," says Castin. "Unreasonable demands make PTs feel as if there aren't enough hours in the day to optimally do their jobs. They also feel that the way they're being asked to work is compromising the safety of their patients."

The latter concern was addressed in an article ² that appeared last spring in Federation Forum, a publication of the Federation of State Boards of Physical Therapy (FSBPT). Summarizing a presentation Berry had made at the organization's annual meeting in 2017, the piece was titled "Occupational Burnout in Physical Therapy: Clinical Implications and Strategies for Reduction."

"A big factor in burnout is feeling compelled to act unethically," the FSBPT publication quoted Berry as having said. "This feeling can happen in some institutions if people are persuaded to overbill due to high productivity requirements or to complete documentation off the clock. With the unethical comes moral distress. Researchers have found that when professionals want to do the right or ethical thing in a situation but can't, due to institutional constraints, they become more morally distressed about their job, leading to a corresponding increase in the rates of burnout."

Berry had given FSBPT a brief primer on the Maslach Burnout Inventory (MBI), which he'd described as the "gold standard" for assessing burnout. First published in 1981 and the primary basis ever since for most burnout research, it's a 22-question measure of 3 dimensions of burnout-emotional exhaustion, depersonalization (instances in which the clinician feels indifferent toward and distant from patients), and feelings of low personal accomplishment.

Those burnout dimensions are robustly evident in physical therapy, Berry told the FSBPT-due not only to productivity and billing practices, but also to factors that prominently include "the impact of the increasing cost of physical therapy education and the large debt incurred by students to obtain that education."

In the decade that ended with the 2014-2015 school year, Berry told the federation, "the cost of PT programs, tuition, and fees went up about 100% at private institutions and about 50% at public institutions." A recent research study of 533 students within 4 months of their graduation, he added, "found that the average loan debt was almost $94,000. Seventy percent [of those recent graduates] had concerns about repaying their student loans." (He'd culled those figures from a 2016 article ³ by Diane Jette, PT, DSc, FAPTA.)

"Debt robs new graduates of options and choices," Berry told FSBPT. "Students with high student loan debt may have to postpone buying homes, having children, or putting money into retirement accounts, leading to personal stress.

"Student loan debt may influence the choice of setting in which a provider works," Berry continued. "New graduates may take a job they don't necessarily want because it pays more money, leading to an unhappy provider and contributing to burnout."

In 2017, APTA surveyed recent graduates (2013-2015) of PT and PTA education programs to learn more about their student debt load and experience. Among the 2,839 PT and 588 PTA responses, 87% of PT respondents had debt from their PT education program. Those with PT education debt owed a mean amount of $107,000. Among PTAs surveyed, 53% reported debt from their PTA education program. The mean debt load from PTA education of those PTAs was $23,000.

Castin says "the school debt-to-income burden" ranks right behind productivity-related concerns among the reasons the PTs she's interviewed, and those who've contacted her, give for their feelings of burnout. While her own debt load was manageable-thanks to savings from her earlier career, scholarship money, and other factors-what Castin often hears from early-career PTs, including those who are otherwise happy in their jobs, is, "I'm barely getting by financially." Many have taken on extra jobs, she says, while others have turned, at least temporarily, to more lucrative employment options such as becoming a travel PT.

The later scenario is fine for PTs who aren't tied to a particular place, but it might not be ideal or stress-free, Castin says. "Some people," she notes, "are put in the position of deciding, 'I guess I can pay off some of my loans if I leave my significant other behind for a year while he or she stays home and takes care of the kids or pets.'"

But productivity- and debt-related pressures are hardly the only drivers of burnout in PTs and PTAs. Individuals contacted for this article also cite the roles played by unrealistic expectations, feeling undervalued, feeling stuck in their current position, and lacking the support of enriching mentorship.

Unrealistic expectations. "When students graduate from their DPT program they have a natural tendency to think they know everything," says Rich Severin, PT, DPT, a clinical assistant professor at Baylor University and a visiting clinical instructor in the University of Illinois at Chicago's Department of Physical Therapy who is a board-certified clinical specialist in cardiovascular and pulmonary physical therapy. "You think you can do anything and manage any case. But it's called clinical 'practice' for a reason," he notes. "Experience matters. Levels of comfort and expertise evolve over time. The learning process never ends. Once you realize and accept that, it actually makes things more interesting and exciting."

Andrew Kneeburg, PT, wonders if instructors always give students an accurate picture of clinical life in 2019. "Some professors are still practicing clinicians, but others may not have been active in the clinic for 25 years," he observes. "Physical therapy's changed a lot in the past quarter-century, in terms of payment, productivity requirements, and other pressures those academicians didn't face in their day."

Kneeburg, who practices at Back in the Game Physical Therapy in the Atlanta area, graduated from PT school in 2016. He wrote a blog post titled "Physical Therapy Burnout: What Leads to It and How to Avoid It" that appeared last June on the website NewGradPhysicalTherapy.com.

"I had a lot of confidence issues when I was fresh out of school," he says. "You quickly find that not everything in 'real life' lines up with what you learned and were told as a student."

Feeling undervalued. For Castin, it wasn't just that her best efforts to meet what she saw as impossible demands were yielding her nothing more than a starring role in the "log of shame." It also was that every time she tried to add to her knowledge and skills base, positive reinforcement was nowhere to be found.

"I always felt like I'd take these continuing education classes and learn new skills that I wanted to use and share with my colleagues, but nobody really cared," she recalls. "As far as many of my employers were concerned, I was there to keep their productivity numbers up, and that was about it."

For PTAs, Hagey notes, feelings of being undervalued or outright disrespected sometimes come from the very practitioners who should know best what PTAs have to offer.

"What I've seen in some of the places I've worked is that there are PTs out there have little or no respect for PTAs, do not value our opinions or input on clinical decisions, and think we're there only to do exactly what they say," Hagey says. "That certainly doesn't describe all or even most PTs, but the message we get from these few is that PTAs bring nothing to the table. And that's a big problem-not only because PTs and patients benefit from the questions we ask and the insights we share, but also because if you start to feel that your role is meaningless, you're going to lose whatever enthusiasm you had for your job."

Feeling stuck. Castin has noted an interesting dichotomy among her fellow PTs since she opted for a nonclinical role in the profession. On the one hand, she feels "stigmatized" by some of her peers, who see patient care as the noblest and, frankly, the only calling of the "real" PT. On the other hand, many PTs, she finds, are intrigued by her shift, want to know more about it, and wonder what nonclinical options might allow them to use their degree in ways that still feel meaningful. Castin created The Non-Clinical PT to delve into those possibilities and to share her findings. She now also offers an online course that's designed to help interested parties identify their strengths and passions, find potential nonclinical matches, create an employment plan, and better ensure nonclinical success-all while remaining engaged in the physical therapy world.

Castin has spoken, as well, to many PTs who feel dissatisfied in their clinical role but can't imagine leaving patient care. Her advice to them is to consider changing employers and perhaps even practice settings before giving up on the clinic. "A lot of PTs find that their feelings of burnout decrease significantly or disappear altogether when they switch to a new organization with a different culture," she says. "Also, if you've only ever worked for a single employer or type of setting, you may be doing yourself a disservice by not exploring other workplaces or avenues. Do you like pediatrics but can't stand the outpatient grind? Perhaps look into school-based PT jobs. Seeking an alternative to working at a skilled nursing facility? Consider outpatient orthopedics-and vice versa."

Hagey, too, has come across PTAs who feel stuck where they are. He likewise encourages them to move on and to consider thinking creatively.

"There's a huge need for more people in the field of quality assurance," he notes. "PTAs can become certified in OASIS auditing and coding," Hagey says, referring to the Outcome and Assessment Information Set that's used in home health. "They can become involved in developing standards for specialized programs in falls prevention and other areas. PTAs," he notes, "can play many different roles in health care."

Lacking mentorship. "I'm a strong believer in the value of mentors to both develop your potential as a clinician and to guard against stagnation that can contribute to feelings of burnout," Kneeburg says. "My boss has been a great mentor to me. He's taught me valuable manual therapy and patient-communication skills. I tell my peers to surround themselves with the right people-people who complain less and educate and inspire more."

Alicia Backer, PTA, "kind of went through the motions and didn't really grow a lot" in her first couple of years out of school. The biggest problem, she reflects now, is that neither she nor her supervising PT at the time knew much about mentorship or understood its value. When she began working with PTs who "saw things in me that I didn't necessarily see in myself" and started seeing her potential as an integral member of the PT-PTA team, Backer felt transformed.

"In many ways, mentorship has defined me as a valued and valuable PTA," says Backer, who also serves as clinic administrator at her employer, RehabAuthority in Thief River Falls, Minnesota. "Mentorship builds trust between PTs and PTAs and reveals the best ways to use the strengths of both parties to benefit patients."

Strategies

The PTs and PTAs interviewed for this article propose a variety of strategies for both guarding against and mitigating burnout.

Productivity and documentation requirements. Generally speaking, there's little downside-and potentially considerable benefit-to prompting conversations and seeking solutions to untenable situations related to productivity demands and documentation dictates. Hagey's aforementioned "hard discussion" yielded positive results for him.

Similarly, Castin says, "Your boss might be thinking, 'I'm just adding 1 more [documentation] form, so it's no big deal.' But if it's a form that's always causing time-consuming glitches in the EMR, that's a good opportunity to engage your boss in a wider discussion," she advises.

"Bring it up in a way that's constructive, and say, 'There are problems with this particular form, but the broader issue is that we're being socked with more and more paperwork. Can we talk about ways of streamlining the process-of making some tweaks in the EMR to create a better flow, so that therapy staff aren't panicking at the end of the day about how backlogged we are on our documentation?"

Kneeburg agrees that documentation demands can "overwhelm" any given clinician. "It's probably the worst part of being a physical therapist," he says. But both employers and PTs and PTAs can do things to decrease the burden.

"At our practice we've worked together to create a template that cuts down on the amount of time needed to complete a record," Kneeburg says. "For example, if you know what measurements you're going to take with a patient with neck pain, and what special tests you're going to conduct, you can insert pertinent passages from the template and individualize them as needed."

Kneeburg adds that PTs and PTAs should ask themselves whether they're documenting as efficiently as they can.

"I'll do some documentation during lunch and first thing in the morning," he says. "I may start a patient's notes before he or she arrives, based on what I already know and can anticipate, then change details later as necessary. I don't just wait until the end of the day. I try to stay on top of it as best I can."

One failsafe way to ease productivity metrics and some paperwork is to switch to an environment in which documenting for reimbursement isn't a factor. And that's not a reference to Castin's nonclinical options.

"Many of my colleagues who have opened or now work at cash-based private practices tell me they're so much happier than they ever were before," says Ellen Zambo Anderson, an associate professor in the physical therapy program at Rutgers University in New Jersey who wrote a doctoral dissertation on stress and burnout in PTs.

Student debt. APTA has created a Financial Solutions Center that offers PTs, PTAs, students, and prospective students resources related to student loan refinancing, financial education, engaging a certified financial planner, scholarship and grant opportunities, and more. The association also addressed the issue in a PT in Motion article ⁴ that explored techniques and strategies for minimizing and managing PT education costs ranging from loan-forgiveness programs, employer assistance, and scholarships to ideas for earning extra money during and after the school years.

PTs and PTAs interviewed for this piece picked up on those themes.

"I have $114,000 in student debt," Kneeburg says. "I worked with a company that helped me refinance my student loan. I'm making a larger payment, but it's at a lower rate. That's going to save me 15 grand in the long run."

"I'd encourage new grads to seek ways to make a little money on the side and gradually chip away at their debt, if they can do so without adding to their stress," Kneeburg adds. "Maybe you can put in a few extra hours working at a hospital or in a nursing home over the weekend. Perhaps you can start an online business of some kind, depending on what your company allows. I know some recent grads and current students who drive for Uber or Lyft."

Castin reiterates that becoming a travel PT, at least for a year or 2, is a lucrative way to make a fast and significant dent in one's student debt load-"provided that's something that works for you in your current life. But, if frequent moves are going to add an undue amount of stress because of the strains they create in your relationships and family life," she adds, "then it's important to recognize that it might not be a good option."

Unrealistic expectations. In his presentation to FSBPT, as described in the Federation Forum, Berry encouraged PT and PTA education programs to follow the lead of the University of New Mexico School of Medicine, which, he said, "provides all of its students with a wellness toolkit that addresses work-life balance and how to assess for burnout."

Berry advised, too, that state physical therapy boards might significantly expand their role in combatting occupational burnout. Such an expansion, he argued, could consist of "communicating with licensees and trying to educate them on the symptoms of burnout," as well as providing them with resources to manage signs of the condition.

"I also think that sometimes we're too hard on ourselves as new grads," Kneeburg says. "From the very start, I wanted to be able to help every patient in some substantial way. It was a bitter pill for me to swallow when I realized that, in some cases, there was only so much I could do to help. That's why I think self-reflection is important. View everything as a learning experience, and try to come to the perspective that all you can do is your best."

Feeling undervalued. "Finding an employer that shares your values is key," Backer says, adding that her current work environment plays a big role in why she doesn't feel burned out. "There's an emphasis here on collegiality, working together to benefit patients, and having fun. They only hire what they call 'OKGs'-'Our Kind of Girl' or 'Our Kind of Guy.' That means that each new hire is someone who's going to fit in with the way we want our clinics to run. The atmosphere is professional but relaxed. Patients always are telling us, 'I'm going to miss coming here'" Backer says.

"We have 2 PTs and 2 PTAs," she continues. "The PTs introduce the PTAs during the initial patient visit and convey right off the bat that we're all part of a team that's going to ensure a great patient experience."

Hagey urges PTAs and PTs alike to speak up if they're feel sidelined or marginalized.

"In the case of PTAs, sit down with your supervising PT and say, 'I'm not feeling like my input is being sought or heard. What can we do to change that?' Don't assume that you're going to get shut down," Hagey says. "Your supervisor might not even have been aware there was a problem. He or she might say, 'We'd love for you to play a stronger role.'"

Confidence issues, too, can affect whether an individual feels valued and valuable, Kneeburg observes. He has benefited, he says, by seeking out books on building confidence.

Feeling stuck. An obvious way to conquer inertia and exit a bad or unproductive situation is to seek a fresh start. That might mean a lateral move within one's existing practice area or a complete change of setting. If, however, "you're simply not happy treating patients, for whatever reason-from productivity and documentation requirements, to the physical toll, to realizing that being around people who are in pain and sometimes take it out on you isn't your thing"-think about exploring nonclinical PT routes, Castin advises.

She cites a few of the many ways in which PTs can "leverage their degree outside the treatment room." They include medical device training and sales, consulting, informatics (information science), marketing, utilization review, health care copywriting or content writing, and rehab intake management.

"I know a PT who went from a clinical role to educating nurses on how to use sensor technology to relieve pressure ulcers," Castin notes. "I think that a lot of opportunities are going to open up for PTs in sensor tech, because it requires understanding how people move, and PTs are the movement experts."

There are other ways to "unstick" oneself besides changing jobs, Hagey notes. "I've spoken at CSM, and I chair the Public Relations Committee of APTA's Home Health Section. Stretching myself in those ways has been rewarding and motivating," he says.

Mentorship. Looking back on her lackluster first years in the profession, Backer says, "I should have educated my supervising PT on my areas of strength, my passions, and my goals-as well as on my weaknesses and areas of uncertainty-so that that, together, we could set objectives and develop a plan for achieving them. If you don't seek out mentorship," Backer warns, "your professional growth may get lost in the shuffle."

For that reason, say the PTs and PTAs interviewed for this article, it's important that staff and supervisors alike seek out continuing education opportunities and offerings at professional conferences that center on mentorship and on strengthening PT-PTA teamwork.

"In addition to my boss, I have a virtual mentor who's helped me with confidence issues," says Kneeburg. He ran across the service in a Facebook ad. "The money I pay is well worth it. I've learned a lot about good ways to handle some of the pressures and challenges we face as new grads."

Involvement in APTA and the community. "I was not an APTA member until a PT who would become a mentor came to work at my clinic," says Backer. "This is a small community, and my viewpoint was pretty narrow. I didn't think I could have any sort of impact in the wider world."

That changed, however, when Backer's mentor, Stephanie Weyrauch, PT, DPT, convinced her to join APTA and enlisted her to participate in a presentation at CSM last year on "Fostering the PT-PTA Relationship to Improve Culture and the Patient Experience."

"Speaking at that conference was a huge experience for me-something I never would have thought I'd be doing," Backer says "It opened up other doors, such as speaking before the [APTA] Private Practice Section late last year. It's been so inspiring. It keeps me motivated and driven."

Similarly, Severin says that attending CSM as a student and seeing firsthand the breadth of the profession was an "eye-opening" experience for him that left a lasting mark.

"Being an active member of our professional organization is important," he says. "It expands your horizons and makes things more interesting. It makes you a part of enacting the laws and effecting other changes you want to see for physical therapy. It gives you an insider's voice to express disagreement with association stances, as well."

Castin concurs. "Being a part of something bigger than just your individual role in physical therapy is a powerful and motivating thing," she says. "And my feeling is, if you don't pull your weight and do your part as an APTA member, you can't complain or get mad when things that you don't like are happening in physical therapy, or when the association is doing things with which you don't necessarily agree."

Severin says that participating in any activity that's directed toward a greater good can be enriching, motivating, and burnout-battling.

"I chair the Social Media Committee for PT Day of Service," he notes, referring to the global volunteering initiative. "It takes you outside yourself and enhances pride in what PTs and PTAs do."

Hagey says community involvement also is part of something that's antithetical to burnout: maintaining a healthy work-life balance.

"I volunteer at our local food pantry," he says. "It's important to have outside interests and pursuits. If everything in your life is your job, that's unhealthy."

Stress-management and self-care. Last, but far from least, advise the PTs and PTAs interviewed for this article: Don't underestimate the power of relaxation and the value of giving yourself a break from the grind.

"Relaxation techniques are valuable in mitigating stress," Anderson notes. "We discuss them in class. I tell my students about the merits of regularly practicing techniques such as deep breathing, progressive muscle relaxation, and meditation."

Castin notes that some employers offer calming services such as free massages. She encourages PTs and PTAs who work in such settings to avail themselves of such perks.

"Use your vacation time," Castin further advises. "You're entitled to it, you've earned it, and typically you need it. Don't be guilted into leaving it on the table. When you skip vacations, it affects your mental state and overall health-and certainly how you feel on the job."

Finally, Castin says, "Don't be too tough on yourself for feeling burned out. It doesn't mean that you're a bad PT or PTA. It just means that you're facing challenges and obstacles that are wearing you down."

"The important thing," she says, "is to take action to address the reasons you're feeling burned out. Be honest with your managers, and see if you can help them streamline processes and eliminate bottlenecks that make achieving productivity goals feel impossible."

Eric Ries is the associate editor of PT in Motion.

References

1. Castin A. Physical therapy burnout is destroying our profession (blogpost). http://covalentcareers.com/blog/physical-therapy-burnout/. Accessed November 1, 2018.

2. Berry J. Occupational burnout in physical therapy: clinical implications and strategies for reduction. http://www.fsbpt.org/Portals/0/documents/free-resources/Spring2018ForumOccupationalBurnoutinPhysicalTherapy.pdf. Accessed November 1, 2018.

3. Jette DU. Physical therapist student loan debt. Phys Ther. 2016;96(11):1685-1688.

4. Tepper DE. How to cope with health care education costs. PT in Motion. 2014;6(2):34-43.

Ripe for Additional Research

References

1. Balogun JA, Titiloye V, Balogun A, et al. Prevalence and determinants of burnout among physical and occupational therapists. J Allied Health. 2002;31(3):131-139.

2. Wandling BJ, Smith BS. Burnout in orthopaedic physical therapists. JOSPT. 1997;26(3):124-130.

3. Schlenz KC, Guthrie MR, Dudgeon B. Burnout in occupational therapists and physical therapists working in head injury rehabilitation. Am J Occup Ther. 1995;49(1):986-993.

4. Donohoe E, Nawawl A, Wilker L, et al. Factors associated with burnout of physical therapists in Massachusetts rehabilitation hospitals. Phys Ther. 1993;73(11):750-756.

5. Anderson EZ. Stress and burnout in physical therapists [dissertation]. https://rucore.libraries.rutgers.edu/rutgers-lib/47324/. Accessed November 1, 2018.

6. Berry JW, Hosford, CC. A regional survey &amp; analysis of burnout among physical therapists in frontier counties. PT-PAL. 2015;15(3):1-11.

APTA Tackles Burnout

# data[].attributes.attachment_link.description
Meredith Castin, PT, DPT, was tired of "being expected to be 3 places at 1 time," then having multiple parties express frustration with her when she failed to do the physically impossible. There also was the psychological toll of constantly being outed in what therapy staff called "the log of shame"-a ledger in which they were required to list their billable units at the end of each day.

# data[].attributes.attachment_link.description
Sleep is your life-support system and Mother Nature's best effort yet at immortality, says sleep scientist Matt Walker. In this deep dive into the science of slumber, Walker shares the wonderfully good things that happen when you get sleep -- and the alarmingly bad things that happen when you don't, for both your brain and body.

# data[].attributes.body
What counts for CE in IL?

# data[].attributes.attachment_link.readable_text
Section 1340.61 Continuing Education

a) CE Hour Requirements

1) Every physical therapist shall complete 40 hours of CE relevant to the practice of physical therapy during each prerenewal period as a condition of renewal. Beginning with the September 2016 renewal, at least 3 hours of the 40 hours must include content related to the ethical practice of physical therapy.

2) Every physical therapist assistant shall complete 20 hours of CE relevant to the practice of physical therapy during each prerenewal period as a condition of renewal. Beginning with the September 2017 renewal, at least 3 hours of the 20 hours must include content related to the ethical practice of physical therapy.

3) A prerenewal period is the 24 months preceding September 30 in the year of the renewal.

4) A CE hour equals 50 minutes. After completion of the initial CE hour, credit may be given in one-half hour increments.

5) Courses that are part of the curriculum of a university, college or other educational institution shall be allotted CE credit at the rate of 15 CE hours for each semester hour or 10 CE hours for each quarter hour of academic credit awarded.

6) A renewal applicant is not required to comply with CE requirements for the first renewal following the original issuance of the license.

7) Physical therapists and physical therapist assistants licensed in Illinois but residing and practicing in other states must comply with the CE requirements set forth in this Section. CE credit hours used to satisfy the CE requirements of another state may be submitted for approval for fulfillment of the CE requirements of the State of Illinois if the CE requirements in the other state are equivalent to the CE requirements in this Section.

b) Approved CE

1) All CE activities shall be relevant to the advancement, extension and enhancement of providing patient/client management, including but not limited to physical therapy examination, evaluation, intervention, and prevention and providing physical therapy services or fulfilling the other professional roles of a physical therapist or physical therapist assistant. Courses not acceptable for the purpose of this definition include, but are not limited to, personal estate planning, personal financial planning, personal investments, and personal health.

2) CE hours may be earned by verified attendance at or participation in a program that is offered by an approved CE sponsor who meets the requirements set forth in subsection (c). Credit shall not be given for courses taken in Illinois from unapproved sponsors.

3) CE may also be earned from the following activities:

A) Teaching a course for an approved CE sponsor or a CAPTE accredited PT or PTA program. An applicant will receive 2 hours of credit for each CE hour awarded to course attendees the first time the course is taught and 1 hour of credit for each CE hour the second time the same course is taught; no credit will be given for teaching the same course 3 or more times. A maximum of 50% of the total CE requirements may be earned through CE instruction. The applicant must be able to provide verification of unique content for each CE course taught via course goals, objectives, and outline.

B) American Board of Physical Therapy Specialties (ABPTS) Clinical Specialist Certification. An applicant will receive 40 hours of CE credit for the prerenewal period in which the initial certification is awarded.

C) American Physical Therapy Association (APTA)-approved post-professional clinical residency or fellowship. An applicant will receive 1 hour of CE credit for every 2 hours spent in clinical residency, up to a maximum of 20 hours. Clinical residency hours may not be used for CE credit if the applicant is also seeking CE credit for hours earned for post-professional academic coursework in the same prerenewal period.

D) Professional research/writing. An applicant may receive CE credit for publication of scientific papers, abstracts, or review articles in peer-reviewed and other professional journals; publication of textbook chapters; and poster or platform presentations at conferences sponsored by any entity that has preapproved status, up to a maximum of 50% of the total CE requirements:

i) 15 hours for each refereed article.

ii) 3 hours for each non-refereed article, abstract of published literature or book review.

iii) 5 hours for each textbook chapter.

iv) 5 hours for each poster or platform presentation or review article.

E) Self-study. A maximum of 50% of the total CE requirements may be earned through the following self-study activities:

i) An applicant may obtain CE credit by taking correspondence or web-based courses, including pre-recorded professional presentations and pre-recorded webinars, from an approved CE sponsor. These courses shall include a test that must be passed in order to obtain credit.

ii) An applicant can receive CE credit for completion of published tests/quizzes based on APTA publications. The applicant will be responsible for verifying successful completion. (These publication-based tests/quizzes, typically offered for less than 1 hour of CE credit, are the only exception to the requirement that all approved CE activities must be at least 1 hour.)

F) Journal clubs. Up to 5 hours of CE credit may be obtained for participation in a journal club. Credit will be earned based on actual hours of participation and must be verified with an attendance list and list of articles from peer-reviewed journals discussed at each meeting.

G) Educational programs at Illinois Physical Therapy Association (IPTA) district meetings. Up to 5 hours of CE credit may be obtained for attendance at these programs. Credit will be earned based on actual hours of participation and must be verified with an attendance list and referenced presentation materials.

H) Departmental inservices. Up to 5 hours of CE credit may be obtained for attendance at inservices at healthcare facilities or organizations. Credit will be earned based on actual hours of participation and must be verified with an attendance list and referenced presentation materials.

I) Up to 5 CE hours may be earned for completion of skills certification courses. A maximum of 2 hours in cardiopulmonary resuscitation certified by the American Red Cross, American Heart Association, or other qualified organization may be accepted, while a maximum of 3 hours may be accepted for certification or recertification in Basic Life Support for Healthcare Providers (BLS), Advanced Cardiac Life Support (ACLS), or Pediatric Advanced Life Support (PALS) or their equivalent.

J) Clinical instructor. Up to 5 hours of CE credit may be obtained by being a clinical instructor for PTA students and up to 10 hours of CE credit may be obtained by being a clinical instructor for PT students. Credit will be earned based on hours of cumulative student clinical instruction, with 1 hour of CE credit per 120 student hours. CE credit hours for clinical instruction will be awarded by the student's academic institution.

K) Virtual attendance at live professional presentations, provided the participant is able to communicate in real time with the speaker and other participants. This shall not be considered self-study under subsection (b)(3)(E).

4) CE will not be awarded for the following types of activities:

A) Entry-level physical therapist or physical therapist assistant academic coursework.

B) Employee orientation programs.

C) Professional meetings or conventions, other than educational programming by approved sponsors.

D) Committee meetings.

E) Work experience.

F) Individual scholarship, mass media programs or self-study activities not identified in subsection (b)(2)(E).

c) CE Sponsors and Programs

1) Approved sponsor, as used in this Section, shall mean:

A) APTA and its components, including programs, courses and activities approved by the IPTA;

B) Federation of State Boards of Physical Therapy, including programs, courses and activities approved through its ProCert program;

C) Colleges, universities, or community colleges or institutions with physical therapist or physical therapist assistant education programs accredited by the Commission on Accreditation in Physical Therapy Education; for post-professional academic coursework, all regionally accredited colleges and universities would be approved sponsors; and

D) Any other person, firm, association, corporation, or group that has been approved and authorized by the Division pursuant to subsection (c)(2) upon the recommendation of the Board to coordinate and present CE courses or programs.

2) Entities seeking a license as a CE sponsor pursuant to subsection (c)(1)(D) shall file a sponsor application, along with the required fee set forth in Section 1340.57. (State agencies, State colleges and State universities in Illinois shall be exempt from paying this fee.) The applicant shall certify to the following:

A) That all courses and programs offered by the sponsor for CE credit will comply with the criteria in subsection (b) and all other criteria in this Section. The applicant shall be required to submit a sample 3-hour CE program with course materials, presenter qualifications and course outline for review prior to being approved as a CE sponsor;

B) That the sponsor will be responsible for verifying attendance at each course or program, and provide a certification of attendance as set forth in subsection (c)(7)(A); and

C) That, upon request by the Division, the sponsor will submit evidence as is necessary to establish compliance with this Section. Evidence shall be required when the Division has reason to believe that there is not full compliance with the statute and this Part and that this information is necessary to ensure compliance.

3) Each licensed sponsor shall submit by September 30 of each even-numbered year a sponsor application along with the renewal fee set forth in Section 1340.57.

4) Each CE program by a licensed sponsor shall provide a mechanism for written evaluation of the program and instructor by the participants. The evaluation forms shall be kept for 5 years and shall be made available to the Division upon written request.

5) All courses and programs shall:

A) Contribute to the advancement, extension and enhancement of professional clinical skills and scientific knowledge in the practice of physical therapy;

B) Provide experiences that contain scientific integrity, relevant subject matter and course materials;

C) Be developed and presented by persons with education and/or experience in the subject matter of the program;

D) Provide for a mechanism for the evaluation of the program by the participants;

E) Be open to all licensed physical therapists and physical therapist assistants and not be limited to the members of a single organization or a group; and

F) Specify the number of CE hours that may be applied toward Illinois CE requirements for licensure renewal.

6) Certificate of Attendance by a Licensed Sponsor

A) It shall be the responsibility of the sponsor to provide each participant in a program with a certificate of attendance signed by the sponsor. The sponsor's certificate of attendance shall contain:

i) The name of the sponsor;

ii) The name of the participant;

iii) A detailed statement of the subject matter;

iv) The number of hours actually attended in each topic;

v) The date of the program;

vi) Signature of the sponsor.

B) The sponsor shall maintain these records for not less than 5 years.

7) The licensed sponsor shall be responsible for assuring verified continued attendance at each program. No renewal applicant shall receive credit for time not actually spent attending the program.

8) Upon the failure of a licensed sponsor to comply with any of the foregoing requirements, the Division, after notice to the sponsor and hearing before and recommendation by the Board pursuant to the Administrative Hearing Rules (see 68 Ill. Adm. Code 1110) shall thereafter refuse to accept CE credit for attendance at or participation in any of that sponsor's CE programs until the Division receives reasonably satisfactory assurances of compliance with this Section.

d) CE Earned in Other Jurisdictions

1) If a licensee has earned CE hours in another jurisdiction from a nonapproved sponsor for which he/she will be claiming credit toward full compliance in Illinois, that applicant shall submit an application along with a $20 processing fee prior to taking the program or 90 days prior to the expiration date of the license. The Division or the Board shall review and recommend approval or disapproval of this program using the criteria set forth in this Section.

2) If a licensee fails to submit an out of state CE approval form within the required time, late approval may be obtained by submitting the application with the $20 processing fee plus a $10 per CE hour late fee not to exceed $150. The Division or the Board shall review and recommend approval or disapproval of this program using the criteria set forth in this Section.

e) Certification of Compliance with CE Requirements

1) Each renewal applicant shall certify, on the renewal application, full compliance with CE requirements set forth in subsection (a).

2) The Division may require additional evidence demonstrating compliance with the CE requirements. It is the responsibility of each renewal applicant to retain or otherwise produce evidence of compliance for a minimum of 5 years.

3) When there appears to be a lack of compliance with CE requirements, an applicant will be notified and may request an interview with the Board, at which time the Board may recommend that steps be taken to begin formal disciplinary proceedings as required by Section 10-65 of the Illinois Administrative Procedure Act [5 ILCS 100/10-65].

f) Waiver of CE Requirements

1) Any renewal applicant seeking renewal of his/her license without having fully complied with these CE requirements shall file with the Division a renewal application, the renewal fee set forth in Section 1340.57, a statement setting forth the facts concerning the noncompliance, and a request for waiver of the CE requirements on the basis of those facts. If the Division, upon the written recommendation of the Board, finds from the affidavit or any other evidence submitted that good cause has been shown for granting a waiver, the Division shall waive enforcement of the CE requirements for the renewal period for which the applicant has applied.

2) Good cause shall be defined as an inability to devote sufficient hours to fulfilling the CE requirements during the applicable prerenewal period because of:

A) Full-time service in the armed forces of the United States of America during a substantial part of the prerenewal period; or

B) Extreme hardship shall be determined on an individual basis by the Board and be defined as an inability to devote sufficient hours to fulfilling the CE requirements during the applicable prerenewal period because of:

i) A temporary incapacitating illness documented by a statement from a currently licensed physician. A CE waiver under this subsection (f) may only be granted for one renewal period and shall not be granted for any subsequent period;

ii) Temporary undue hardship (e.g., prolonged hospitalization, being disabled and unable to practice physical therapy on a temporary basis).

3) If an interview with the Board is requested at the time the request for the waiver is filed with the Division, the renewal applicant shall be given at least 20 days written notice of the date, time and place of the interview by certified mail, return receipt requested.

4) Any renewal applicant who submits a request for waiver pursuant to subsection (f)(1) shall be deemed to be in good standing until the Division's final decision on the application has been made.

(Source: Amended at 42 Ill. Reg. 14185, effective July 11, 2018)

# data[].attributes.attachment_link.description
Section 1340.61 Continuing Education a) CE Hour Requirements 1) Every physical therapist shall complete 40 hours of CE relevant to the practice of physical therapy during each prerenewal period as a condition of renewal. Beginning with the September 2016 renewal, at least 3 hours of the 40 hours must include content related to the ethical practice of physical therapy.

# data[].attributes.attachment_link.readable_text
Gary Greenberg published an excellent piece in the New York Times magazine entitled "What if the Placebo Effect Isn't a Trick"?

This well researched essay walks us through the history of the placebo effect, our current scientific understandings, and what effect these might have on western medicine. He describes the recent conference of the Society for Interdisciplinary Placebo Studies and how we now have an abundance of evidence that if people with chronic stress-related conditions receive a sugar pill from a provider in whom they have confidence, they will register the strongest placebo effects and will improve. Time and again what are shown to strengthen patient's response to "inert" substances is the mechanism by which they are delivered. Specifically, when the "intervention" is delivered by a warm, friendly, and trusted clinician who is paying close attention to the patient the results are amplified.

We are in a new era of physical therapy where we are moving away from the focus being on the "intervention" as the single type of exercise, manipulation, or pain education. In this new era, we are embracing the Physical Therapist "package of care." Each step along the clients encounter with our services can have a positive or negative impact on their well-being. The first friendly and caring voice they hear on the phone or the kind image on your website matters directly to their future outcome. The ability to have all team members listening and caring with their whole-body matters. The ability to sit quietly and listen to our client's story followed by asking the right question at the right time matters. The highly skilled and elegant physical examination matters. The skilled, gentle, and effortless manipulation of a body region matters. The least complex and most easily grasped and executed exercise program matters. The gentle hand on a shoulder when the tears come matters. The laughter, motivation, and the nudging of meaning back into one's life matters.

Each of these attributes of the modern day effective physical therapist are important. It is indeed the package of care that we deliver that matters and we must strive to excel across all of these domains.

# data[].attributes.attachment_link.description
Gary Greenberg published an excellent piece in the New York Times magazine entitled "What if the Placebo Effect Isn't a Trick"? This well researched essay walks us through the history of the placebo effect, our current scientific understandings, and what effect these might have on western medicine.

# data[].attributes.body
A study on women with and without migraines and role of cervical muscles

# data[].attributes.body
Good resource for patients!

# data[].attributes.headline
Recommendations- Exercise Dosage for Pain

# data[].attributes.subject
Recommendations- Exercise Dosage for Pain

# data[].attributes.attachment_link.readable_text
EXERCISE DOSING FOR PAIN IS NOT THE SAME AS EXERCISE DOSING FOR FITNESS!

Exercise dosage in rehab is still one of the biggest areas of uncertainty in clinical practice. On one hand we have modern thinking that promotes higher loading & dosage for patients and on the other hand we have the traditional model of lower load and lower dosage that has probably evolved to minimise the risk of adverse scenarios such as increased pain and decreased patient confidence in the therapist.

Currently we have some basic dosage guidelines for rehab that focus on the physical qualities that we know can be a PART of rehab. But if we take the primary target of the majority of rehab, PAIN, and if we are being honest with our current knowledge base, we don't really have the sets and reps, or other dosage parameters that we can use to achieve a reliable outcome on our patients pain.

If we look at the current research base for rehab exercise we regularly see that the confidence intervals around the mean effect for pain cross zero meaning that the possibility of a large, small, no or even an adverse effect are all still a possibility.

Rough current physical dosage parameters

Endurance 12+. 2-3 sets.

Hypertrophy 6-12, 3-6 sets

Strength 6 or less, 2-6 sets

Power 1-2 reps, 3-5 sets.

Unfortunately NONE of these things relate well to pain and that makes a lot of sense but also throws in some confounding. We know pain is a multi dimensional experience so for one factor to reliably relate well to pain makes little sense, but the issue is that the one factor (exercise) may also have an effect on multiple dimensions associated with pain as well, so this becomes a little confusing : ). Maybe the key here is the word reliable?

So if we want to improve these physical aspects in rehab then we do have some parameters to work with. The question is can we simply port over what we know about exercise over to rehab exercise and pain?

I don't personally believe so.

So Lets NOT say physical parameters are unimportant but also acknowledge that expecting a traditional view of exercise and exercise dosing to have a predictable effect on pain may not be prudent or correct.

A principle often discussed in relation to exercise programing is the SAID principle, Specific Adaptation to Imposed Demand, this means that the body will always adapt to the stimulus applied. Now this is a principle that will hold true always, although HOW the body adapts is still pretty individual and often not easy to predict.

BUT the problem is that we expect the thing we can specifically target with our current dosing knowledge, lets say strength with a rep range of 6 or under and a load that reflects that, will have a predictable and specific relationship with ANOTHER therapeutic target, PAIN.

So we are not really being specific in this case at all as there is a disconnect between the targeted physical outcome, and associated dosing parameters, and the outcome of pain.

Rather than just physical adaptations, a modern view of rehab might start to think about some of the things that exercise might affect that have a positive impact on patients. To get a specific effect from these things we might have to think about programming specifically to achieve these outcomes rather than suggest our current rehab dosing will automatically improve them.

Therapeutic exercise targets:

Pain (the big confounder)

Specific functions (physical qualities are a part of but not all of this)

Fear avoidance & psychological measures (proving very important in outcomes & prognosis)

Confidence & motivation

Freedom of movement/relaxation

Movement strategy

Adherence

EXERCISE RESEARCH

If we take recent work by O'Neill HERE that looked at acute analgesia (instant pain relief) we see that the set dosage used in this study, looking at individual responses, produced variable responses on pain, even INCREASING pain, especially if the patients baseline pain was already high.

Another paper HERE looks at different exercise types effect on pain and an interesting recent paper HERE discussing mechanisms and individuality with pain responses to exercise.

Lets take a look at some exercise comparison studies where pain was part of the primary outcome measure. We see that different programs with different dosing parameters have similar outcomes. We also have to be aware that if we are looking at the mean effect of exercise on pain this may mask the low and high responders to the differing dosage levels.

This study HERE compared low and high load exercise programs for rotator cuff tendinopathy

This study HERE compared high (deadlifts) and low load (motor control exercises) for back pain. The conclusion from this group's research was that higher load was more applicable for those with lower pain.

This study HERE looked at different loading programs for Achilles tendinopathy

Exercise for pain perhaps should not always be seen as something that will reduce pain in the short term, as we might see with the concept of exercising/moving to change symptoms. Instead it might be moving with a TOLERABLE amount of pain that increases pain self efficacy and keeps the body moving during pain is an equally important scenario.

Remember tolerance should really be PATIENT DEFINED. Exercise has the potential to increases our patients pain as well as reduce it and anyone in clinical practice who has flared a patient up with exercise knows this! The concept of optimal loading is really about tissue/physiological adaptations, but perhaps we also need to apply this optimal loading concept to pain adaptations, increases in pain, staying within current symptomatic levels and also decreases in pain.

We know that exercising WITH pain does not produce worse outcomes HERE. I have previously written about this HERE

CURRENT STATE OF THE PATIENT

So within the concept of tolerance we have to consider the current state of our patient with regards to dosage. It is tough to reconcile the concept of tolerance within a model of changing strength, ROM etc for me, as this does not consider things that might affect our patient's tolerance to exercise.

Things that might affect our patients pain tolerance

Current/previous levels of exercising

Stress levels

Sleep behaviour

Anything that is associated with increased pain sensitivity to stimulus

One of my favourite clinical reasoning tools is the SIN analysis from Maitland. Lets not go too much into the Nature (type of pain), but severity (how much it currently hurts) and irritability (how long it hurts vs stimulus applied) really equal the modern concept of sensitivity. One of the key factors in 'sensitivity' is disproportionate stimulus and response (level and duration of pain or severity and irritability). This then would inform our clinical reasoning by reducing the stimulus or exercise dosage in line with current levels of sensitivity.

RATE OF PERCEIVED EXERTION (RPE)

One of the measures I use to gauge dosage is effort level via the borg scale. This is far more subjective than using sets and reps in a traditional fixed sense and remember pain is a pretty subjective experience!

<

One of the hardest things is to keep our exercise dosing within tolerable limits in the beginning, or dose titration, when we have limited or no knowledge of our patients response. I tend to use a pain VAS (yes I know it's a crap measure!) vs RPE. So if VAS is high then I make sure effort level is lower. I tend to find this keeps responses within tolerable limits, but of course not always.

I call this the rule of 10, so both numbers add up to.....you guessed it 10! Example would be if pain is a VAS of 7 then I would keep RPE to a 3. If pain was low, say 3 on the VAS then I would maybe take the RPE up to 7.

But if you feel your patient is highly stressed, fearful or under slept then any of these things might have to be factored in to the dosage thought process if you want to keep the dosage within a tolerable response.

MONITOR RESPONSE TO DOSE!

The most important thing is to monitor the response to the dose. Lets say we play it sensible and keep RPE low because of a higher VAS, and the patient finds it easily tolerable well then we know we can push it a bit harder and load em up. If we get an adverse reaction even though we kept the effort or load down then we may have to drop it even further.

BE OK IN THE GREY

We will never really know what the dosage should be until we actually apply the dosage and then monitor the response. So its OK not know what's going to happen, just use your 'loaf of bread (head)' and be OK with sometimes getting it wrong. Don't panic, just adjust the dosage and educate that this is normal, it's definitely not an exact science and often trial and error.

PEOPLE WILL ALWAYS WANT SOME KIND OF DIRECTIONS

One of the issues can be that people want to know how much to do and have some kind of direction. This usually end ups as 3×10 once a day (be honest, you have said this!) and I can understand why this is given as it is really quite difficult to be more specific. This is why explaining that it is a bit of trial and error with some good reasoning and also helping the patient to understand what a flair up might be/mean is important.

CONCLUSION

We currently don't have an exercise dosage for pain

Pain does not respond consistently to current dosing parameters

There are other therapeutic targets apart from physical aspects

Exercise data does not support current dosing ideas in rehab

Think about the current state of the patient with regards to dosing levels

Use clinical reasoning

Be OK in the grey

# data[].attributes.attachment_link.title
Exercise dosing for pain is not the same as exercise dosing for fitness! - Physio Network

# data[].attributes.attachment_link.description
EXERCISE DOSING FOR PAIN IS NOT THE SAME AS EXERCISE DOSING FOR FITNESS! Exercise dosage in rehab is still one of the biggest areas of uncertainty in clinical practice.