Adverse Reponse to Exercise: Rare or Common?

We just don't know.

This study Adverse Metabolic Response to Regular Exercise: Is It a Rare or Common Occurrence? was reported in PLoS One yesterday (online).

This is the first study like this I've ever seen. According to the study authors:

"Whether there are people who experience adverse changes in cardiovascular and diabetes risk factors has never been addressed."

This just underscores the need for physical therapists to monitor basic, cardiovascular signs in response to exercise.

• Blood pressure
• pulse
• respiratory rate
• oxygen stauration
• rate of perceived effort
• et al

Acocrding to Jette and Jewel in the April 2012 PT Journal:

• only 11% of physical therapists routinely measure blood pressure
• only 38% of physical therapists routinely measure Body Mass Index (BMI)
• only 21% of physical therapists routinely advise patients to quit smoking
• only 29%% of physical therapists routinely complete a neurological examination in diabetic patients
• only 26% of physical therapists routinely complete a footwear examination in diabetic patients
• only 6% of physical therapists routinely measure gait velocity in their older patients

I'd like to see physical therapists advocate to change our state practice acts so that we could penetrate the skin and collect blood samples to measure important factors in assessing exercise response, included in this study:

• fasting plasma HDL-cholesterol (HDL-C)
• triglycerides (TG)
• insulin (FI)

At least one state physical therapists' association was successful in 2011 in increasing their scope of practice to allow penetration of the skin.

But, before changing state practice acts we need to measure the basic stuff.

Otherwise we'll never know.

The Severity and Intensity Model for Physical Therapists

"I'm sorry, Mrs. Smith, but we can't continue your physical therapy - you've hit your Medicare Cap."

"But I'm doing better and I've not missed even one of my 16 visits. My doctor wants me to finish another month of PT - why won't Medicare pay?"

"Well, that's just it - Medicare will pay but your physical therapist's documentation shows you ARE better and we're afraid if we let you come for more PT then Medicare will deny payment."

"Can't you write down how much physical therapy helps me and how I NEED this?"

Physical therapists in America every day face Mrs. Smith. I've faced Mrs. Smith.

The above conversation is hard on Mrs. Smith and hard on physical therapists.

The new proposed Severity and Intensity Alternative Payment System is supposed to help physical therapists write notes that show how much Mrs. Smith needs her physical therapy.

The American Physical Therapy Association's (APTA) draft of the proposed Alternative Payment System for Physical Therapy Services describes how physical therapists can write notes that show Medical Necessity for Physical Therapy.

Medical Necessity is important when you need to justify your Plan of Care - for example if you apply the -KX modifier to attest that your patient needs PT in excess of the 2012 Cap of $1,880 for combined PT and Speech services.

Guccione et al in the September 2011 PT Journal described in detail their concept of how the Severity and Intensity model will work.

The Severity and Intensity model proposes a daily case rate to pay physical therapists' based on the mental effort and judgements we make during a patient visit.

The Severity and Intensity model will de-emphasize time as most valuable component of the physical therapist's service. The Severity and Intensity model will describe...

"...a broader conceptualization of work that emphasizes continuous examination and the multiple components of clinical decision making and patient care management will facilitate the determination of medical necessity and appropriateness of care."

Non-members of the APTA can read an overview of the Draft here.