FINAL 10 17 APTA WEbinar 10 23 14 Final an Annual Physical Therapist Checkup? • The Need – Prevalence of chronic medical conditions, lifestyle behaviors, and disability

© 2012 American Physical Therapy Association 1

Why an Annual Checkup Should and Could be a Service Your Clinic Offers

David Taylor, PT, DPT, GCS

Jon Delk, PT, MSPT

Introduction

David Taylor, PT, DPT, GCS is a Clinical Assistant Professor in the Department of Physical Therapy at Mercer University, in Atlanta Georgia. Dr. Taylor received his B.S. in Psychology in 1988, Master of Physical Therapy in 1992, and Doctor of Physical Therapy in 2004 from Emory University. He has been a Board Certified Clinical Specialist in Geriatric Physical Therapy since 2001. Dr. Taylor’s teaching responsibilities include health promotion, geriatric physical therapy, service‐learning, and clinical education. Dr. Taylor was the recipient of the 2014 Lynn Phillippi Advocacy for Older Adults Award from the Academy of Geriatric Physical Therapy.

©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited. 2

Introduction

• Jon Delk, PT, MSPT Delk graduated from East Carolina University with a Bachelor of Science degree in Chemistry. He was a four‐year member of the ECU Football staff as a coach’s assistant from 1993‐1997. From there Jon went to the University of Alabama‐Birmingham where he received a Master of Science degree in Physical Therapy in 1999. He has been with Eskridge and White Motion Therapy (EW) since 2001 and is the Clinic Director. Jon co‐founded EW Fit, a fitness, training, and wellness company within EW, in 2005. His clinical specialties include manual therapy, functional exercise application and post‐operative rehabilitation in athletes. Jon has had the opportunity to work with several collegiate and semiprofessional athletes throughout his career.



DISCLOSURE:

David Taylor, PT, DPT, GCS

No disclosure

Jon Delk, PT, MSPT

Principal Eskridge and White Motion Therapy

4©2014 American Physical Therapy Association. All rights reserved. All reproduction or redistribution prohibited.

Learning Objectives

• At the conclusion of this webinar participants will be able to:

1. Describe the importance of all standardized elements of the Annual PT Checkup.

2. Apply the aspects of EBP to the Checkup process.

3. Describe a model used in clinical practice for implementing the Annual PT Checkup.

4. List business considerations for offering this service.

5. Utilize APTA resources to provide Annual PT Checkups in their clinics.


Agenda

• The Annual Physical Therapist Checkup

– David Taylor, PT, DPT, GCS

• The Annual Physical Therapist Checkup –A Model for Clinical Practice

– Jon Delk, PT, MS

• APTA Resources

– Lisa Culver, PT, DPT, MBA

• Question and Answer Session with presenters


POLL 1:WHAT IS YOUR CURRENT PRACTICE SETTING?

OUTPATIENT PRIVATE PRACTICE

OUTPATIENT HOSPITAL‐BASEDSKILLED NURSINGHOME HEALTHACUTE CAREOTHER


POLL 2:ARE YOU CURRENTLY PERFORMING AN ANNUAL PT CHECKUP VISIT OR FITNESS TESTING IN YOUR PRACTICE?YESNO


The Annual Physical Therapist Checkup


Part 1 Overview

• Why and Annual Physical Therapist Checkup?

• Annual Physical Therapist Checkup Elements– Personal Health Profile

– Disease Risk Profile

– Standard Physical Exam

– Physical Performance Exam

– Health Risk Evaluation and Summary

– Personal Wellness Plan and Exercise Prescription

– Management and Outcomes


Why an Annual Physical Therapist Checkup?

• The Need

– Prevalence of chronic medical conditions, lifestyle behaviors, and disability

• Current Health Care Annual Checkup Models

• The Evidence

– U.S. Preventative Task Force Recommendations

The Physical Therapists’ Role

• The Guide to Physical Therapist Practice

• APTA Position

• Practice Categories

• Development of the Annual PT Checkup

• Considerations for the Annual PT Checkup


The Physical Therapists’ Role

• The Guide

– “intervention, prevention, and the promotion of health, wellness, and fitness are a vital part of the practice of physical therapists.”

– Screenings determine the need for:

• Primary, secondary, tertiary prevention services

• Further examination, consultation by a PT

• Referral to another practitioner

Health

Health Promotion

Wellness

FitnessPrevention

Disease Management


Poll Question

• Which of these do you want to improve in your practice?

– Disease Management

– Fitness

– Health Promotion

– Prevention

– Wellness



Evolution of the Annual PT Checkup


Patient/Client Management Model

Age Ranges (21‐65)

Time (30‐60 min)

Expectations (Documentation & Additional Testing)


Clinical Judgment

• “ The physical therapist may decide to use one, more than one, or portions of several specific tests and measures as part of the examination, based on the purpose of the visit, the complexity of the condition, and the directions taken in the clinical decision‐making process.” (Guide 3.0)



Elements of the Annual PT Checkup

Evaluation

Summary of FindingsIndividualized Exercise

PrescriptionOutcomes Management

Physical Performance Exam

Aerobic CapacityBalance

(Static/Dynamic)Locomotion Speed

Mobility ,Flexibility Functional Strength

PostureQuality of Movement

Standard Physical Exam

Body Mass Mental Status Sensation Resting Vital Signs

Disease Risk Profile

Current Health Profile & Behaviors Disease Risk Stratification Emotional Status, Hearing, Integ, Vision, Pain

Personal Health Profile

Individual Goals & Aspirations, QOL

DemographicsMedical & Surgical History

MedicationsPersonal Factors


Personal Health ProfileGoals

Aspirations QOL

PROMIS Global Health Scale

SF12 or SF 36

Alternatives

Stroke Impact Scale

Parkinson’s Disease Questionnaire‐39

Demographics

Age Sex

Race/Ethnicity

Education level

Occupation &

Employment Status

Adequate Food/Housing

Healthcare Access

Medical History

Medical / Surgical / Family

Specific to Men Women

Medications OTC Supplements

Personal Factors

Communication / Learning style

Language Self‐efficacy

Environmental Factors Abuse / Neglect Screening




• Activity Classification

• Meeting National Physical Activity Guidelines

• Sedentary Behaviors / Time Sitting

• Nutrition

• Alcohol/ Drug Use

• Smoking History

Current Health Status & Behaviors

• ACSM: Low, Moderate, High OR

• BMI / Waist CircumferenceDisease Risk

• 3 question screen OR

• PROMIS ScalesEmotional Screen

• Do you feel you have hearing loss?

• CALFRASTHearing

• Risk screenIntegument

• Snellen ChartVision

• PROMIS Scale for Pain Interference

• NPR/VASPain


Standard Physical Exam




Six Minute Walk Test

OR

Walk, run, cycle,

Step or Treadmill

Alternatives

A6MCT

USCD‐SOBQ

Aerobic Capacity: Field Test

Static Single Leg Stance

Dynamic

Hexagon Agility Test

Four‐Square Step Test

Alternatives

ABC Scale for MS

BBS for Stroke

Static & Dynamic Balance

10‐meter

walk test

Alternatives

10‐MWT for CP

10‐MWT for PD

Locomotion Speed


Core Strength

McGill Test

Trunk Extension &

Side bridging L / R &

Anterior Trunk

Functional Strength

Sit‐to‐Stand (30 second) &

Push up &

Hand‐held Dynamometer Grip

Strength

Flexibility

Apley’s

Scratch Test

&

Sit and Reach

Alternatives

TUG for PD

LEFS for TKR

Neck Disability Index


Classification

(Kendall, 2005)

Rib to Pelvis Distance

>40 years of age

Posture

Sit‐to‐Stand

Overhead Reach

Floor Reach

Forward Reach

Quality of Movement



Interpretation

Consultation

Referral

Wellness Plan

Lifestyle Conditions

Lifestyle Behaviors

Individualized Exercise Prescription

Services

Reexamination

Outcome Tracking & Reporting


Why an Annual Check Up Should and Could Be a Service Your Clinic

Offers

The Annual Physical Fitness Evaluation Model

The Annual Physical Fitness Evaluation Model

• History of Development

• Business Considerations For Implementation

• Case Example

• Demographics/Statistics


History

• PT Access laws in 2007

• We are referring patients to outside sources for wellness/fitness needs post Physical Therapy

• Created Wellness Company in space contiguous with PT clinic

• Initial challenges

• Initial success

History

• Developed the Physical Fitness Evaluation Program

• Initially designed to strengthen relationship with MD group

• MD group was concierge practice and was performing annual check up that included medical evaluation and nutrition services

• Fitness Evaluation performed by a non‐PT employee of wellness company

The Fitness Evaluation

• Initial subjective history and questionnaire. Evaluation assesses height/weight, vital signs, UE/LE functional strength and mobility, balance, agility, core stability, body composition and cardiorespiratory fitness


The Fitness Evaluation

• Results reviewed with client and report sent to MD for baseline

• Based on results/deficits a fitness program or supplement to current program is developed

• Client returns for one follow up “instructional session”


Tests Used in Fitness Evaluation

• Lower Extremity Strength – Sit to Stand

• Upper Extremity Strength – Push Up, Handgrip

• Lower Extremity ROM – Sit/Reach

• Upper Extremity ROM – Back Scratch

• Agility – 8 Foot Up/Go, Cone Drills

• Core Stability – Plank Progression

• Body Composition – Bioelectrical Impedance

• Cardio – 6 Minute walk, Bruce Submax, AirdyneFitness

Sample Fitness Evaluation Report


Sample Fitness PrescriptionMuscular Strength / ConditioningType: Continue current program with additional core strengthening exercisesIntensity: ModerateDuration: 1‐2 exercises per major muscle group2‐3 sets of 10‐20 repetitions per exerciseFrequency: 2‐3 days per week

Cardiorespiratory Fitness Type: CyclingIntensity: Moderate – highTarget Heart Rate = 134 – 154 beats per minuteDuration: 30‐60 minutesFrequency: 3‐5 days per week

FlexibilityType: Stretches provided in packet

Intensity: To the point of tightness, NOT PAIN

Duration: Hold each 5‐10 seconds, 5 times

Frequency: Everyday!

Special Considerations

Always maintain a neutral spine posture when performing strength exercises. Be sure to stretch after each exercise session while muscles are warm. Discontinue any exercise if it causes pain. Please call or e‐mail me if you have any questions regarding your fitness assessment or exercise prescription. Keep up the good work!

©2014 American Physical Therapy Association. All rights reserved. All

reproduction or redistribution prohibited.37

Fitness Prescription

©2014 American Physical Therapy Association. All rights reserved. All

reproduction or redistribution prohibited.38

The Fitness Re‐Evaluation

• Performed as close to year anniversary as possible

• Slightly less expensive

• Same tests performed and results compared in a table

• Table indicates progress or decline in each area as compared to previous year


Sample Fitness Re‐Eval Report

July 2013 – Direct Access

• State law changed to allow for direct access

• Explanation of law

• Allowed PTs to become involved in this process

• Patients can now opt to come to our facility for this service without an MD referral

• Fitness evaluation client may become PT patient

Business Considerations for Implementation

• Staffing

• Equipment

• Insurance Coverage

• Space

• Marketing/Promotion

• Your Brand

• Key Competitive Capabilities

• Success Factors


Staffing

• Non‐issue if PT or multiple PT staff intact

• May consider hiring a certified fitness instructor (personal trainer)

Equipment• Evaluation tools will vary based on choice

of tests

• Movement screening tool, hand dynamometer, BP cuff, HR monitor, treadmill, Airdyne, plyo boxes

• Evaluation software and laptop

• Office supplies

Insurance Coverage

• Liability coverage

• Not as expensive for non‐professional (PT) staff


Space

• Extensive use of space

• Consultation area

• Space for follow up services (personal or group fitness training)

Marketing/Promotion

• Discussion of laws regarding marketing a free service

• Targets

• Cross‐consulting with other health care providers (PTs)

Your Brand

Does it fit with the image or culture of your clinic?


Key Competitive Capabilities

• Very little existing competition

• Already trusted authority in your community

Success Factors

• Qualified personnel

• Valuable evaluation tools, tests and methods

• Fitness program knowledge

• Clean/Spacious environment

• Ability to follow up

Case Example – 74 year old male

• Fitness Evaluation in 2011 – history of falls

• Results – poor body composition, lower/upper extremity strength/ROM

• Began training 1 month later

• Fell at home and injured RTC in 2012


Case Example

• Did 4 weeks of PT in clinic

• Regained full shoulder strength and ROM –returned to training

• Still training at our facility today

• 78 years old. Can perform squats, deadlifts, push ups and overhead press pain free


Demographics/Statistics• 90% of referrals are 60‐90 year old retirees

• Have received over 300 fitness eval referrals since 2008

• 90% show for fitness evaluation

• 75% elect for follow up instructional session

• 60% return for I year follow up (declines each year)

• 10% become regular training clients

• 35% have become PT patients at some point since their evaluation

• Fitness evaluation referrals make up about 15% of total current fitness clients

APTA Resources

Lisa Culver, PT, DPT, MBA


APTA Resources

• www.apta.org/annualexamination

• Healthy population examinations by age groups

• Links to alternative tests for individuals with disease and disability requiring a different tests

• What if I don’t find what I want?

• Additional sources and EBP

Summary

• The Annual Physical Therapist Checkup

– Health Promotion and Prevention

– Standardized Elements

– Clinical judgment

– Integrates into practice

– Addresses need

– Resources available to support practice


Thank You

• Contact information

• David Taylor: [email protected]

• Jon Delk: [email protected]

• Lisa Culver: [email protected]


References• American College of Sports Medicine, eds. ACSM’s Guidelines for Exercise Testing and Prescription. 9th ed.

Baltimore, MD: Lippincott, Williams & Wilkins; 2013.• American College of Sports Medicine, eds. ACSM’s Health‐Related Physical Fitness Assessment Manual. 3rd ed.

Baltimore, MD: Lippincott, Williams & Wilkins; 2010.• Arroll B, Goodyear‐Smith F, Kerse N, Fishman T, Gunn J. Effect of the addition of a “help” question to two screening

questions on specificity for diagnosis of depression in general practice: diagnostic validity study. BMJ. 2005;12(7521):884

• Beekhuizen K.S., Davis M.D., Kolber M.J., Cheng M.S. (2009) Test‐retest reliability and minimal detectable change of the hexagon agility test. J Strength Cond Res 23, 2167‐2171.

• BMI/Waist Circumference Index. Available at: http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/bmi_dis.htm

• Casanova C, Celli BR, Barria P, Casas A, Cote C, de Torres JP, et al. The 6‐min walk distance in healthy subjects: Reference standards from seven countries. Eur Respir J. 2011;37:150–6.

• Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services; 2014. Available at: http://www.cdc.gov/diabetes/pubs/statsreport14.htm. Accessed 10/4/2014.

• Centers for Disease Control and Prevention. Age‐Adjusted Percentage of Adults Aged 18 Years or Older with Diagnosed Diabetes Who Were Physically Inactive, United States, 1994–2010. Atlanta, GA: US Department of Health and Human Services; 2014. Available at: http://www.cdc.gov/diabetes/statistics/comp/fig9.htm. Accessed: 10/5/2014.

• Feldhaus KM, Koziol‐McLain J, Amsbury HL, Norton IM, Lowenstein SR, Aboott JT. Accuracy of three brief screening questions for detecting partner violence in the emergency department. JAMA. 1997;277(17):1357–1361.

• Gans KM, Ross E, Barner CW, Wylie‐Rosett J, McMurray J, Eaton C. REAP and WAVE: New Tools to Rapidly Assess/Discuss Nutrition

• with Patients. J Nutrit. 2003;133:556S‐562S.• Guide to Physical Therapist Practice. 3rd ed. Alexandria, VA: American Physical Therapy Association; 2001. Rev.

August 2014.• Hexagonal Obstacle Test. Available at: http://www.brianmac.co.uk/hexagonal.htm


References• Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function, with Posture

and Pain. 5th ed. Baltimore, MD: l Lippincott, Williams & Wilkins; 2005.• Magee DJ. Orthopedic Physical Assessment, 5th ed. Philadelphia, PA: Elsevier Health Science; 2007.• McGill SM, Childs A, Leibenson C. Endurance times for low back stabilization exercises: clinical targets for testing

and training from a normal database. Arch Phys Med Rehabil.1999;80:941‐944.• PQRS foot screen. Available at: www.mdinteractive.com/files/uploaded/file/.../Measure163‐2014cms.pdf .

Accessed: April 22, 2014.• Paxton AE, Strycker LA, Toobert DJ, Ammerman AS, Glasgow RE. Starting The Conversation Performance of a Brief

Dietary Assessment and Intervention Tool for Health Professionals. Am J Prev Med 2011;40(1):67–71.

• PROMIS Short Form Instruments. Available at: https://www.assessmentcenter.net/PromisForms.aspx• Siminoski K, Warshawski RS, Jen H, Lee KC. Accuracy of physical examination using the rib‐pelvis distance for

detection of lumbar vertebral fractures. Am J Med 2003;115:233‐6.• Six‐minute Walk Test. Available at: http://www.ptnow.org/. Accessed April 22, 2014.• Stevens S. Test distance vision using an eye chart. Community Eye Health. Sep 2007; 20(63): 52. Available at:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040251/.• Torres‐Russotto D, Landau WM, Harding GW, Bohne BA, Sun K, Sinatra PM. Calibrated finger rub auditory

screening test (CALFRAST); Neurology. 2009 May 5; 72(18):1595‐1600.• U.S. Census Bureau, 2004 Survey of Income and Program Participation, Wave 5, June‐September 2005. as reported

in: Hootman JM, Brault MW, Helmick CG, Theis KA, Armour BS. Prevalence and Most Common Causes of Disability Among Adults —United States, 2005. MMWR 2009;58(16):421‐426.

• US Department of Health and Human Services. Physical activity guidelines advisory committee report, 2008. Nutrition Reviews. 2009;67(2):114‐120.

• U.S. Preventive Services Task Force. Behavioral Counseling to Promote a Healthful Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Final Recommendation Statement. AHRQ Publication No. 13‐05179‐EF‐2. Available at: http://www.uspreventiveservicestaskforce.org/uspstf13/cvdhighrisk/cvdhighriskfinalrs.htm


Screening Questions• Abuse/Neglect (Feldahus, JAMA, 1997)

– Do you feel safe in your current relationship?– Is there a partner from a previous relationship that is making you feel

unsafe now?– Have you been hit, kicked, punched or otherwise injured within the past

year? If so, by whom?

• Nutrition– “ what can you do to improve your diet?”– REAP and WAVE (Gans, 2003) / Starting the Conversation (Paxton, 2011)

• Alcohol Use– “How many times in the past year have you had 5 drinks (men) or 4

drinks (women and all adults >65 yo) or more in a day?”

• Smoking – “Do you smoke or have you quit smoking within the previous 6

months?”



Screening Questions

• Emotional Status (Arroll et al, BMJ 2005) – “During the past month have you often been bothered by feeling down, depressed, or hopeless?”

– “During the past month have you often been bothered by little interest or pleasure in doing things?”

– “Is this something with which you would like help?”– Optional: “Is this something you would like to address in the near future?”

• Hearing– “Do you feel you have a hearing loss?”


Documents

FINAL 10 17 APTA WEbinar 10 23 14 Final an Annual Physical Therapist Checkup? • The Need – Prevalence of chronic medical conditions, lifestyle behaviors, and disability