PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA

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PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
FOR MEMBERS OF THE AMERICAN PHYSICAL THERAPY ASSOCIATION   SEPTEMBER 2017

On the Menu: Nutrition-Related
Physical Therapist Services

NEXT 2017
Coverage

PTs and
Chronic Fatigue
Syndrome
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
Bioness Spread
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
Vol 9 No 8   SEPTEMBER 2017

26        NUTRITION: A PORTION OF PTs’
                                                                                               DEPARTMENTS
          MENU OF SERVICES
          Diet and nutrition are key factors in managing many conditions                          4 DID YOU KNOW?
          that PTs treat. Here are some insights from clinicians who offer
          nutrition-related services.
                                                                                                 6 VIEWPOINTS

                                                                                                44 PROFESSIONAL
                                                                                                   PULSE

    16
                                                                                                 + Data Points
                                                                                                 + Health Care Headlines
                                                                                                 + Update On Opioids
                                                                                                 + Research Roundup
    THE REAL STORY                                                                               + Association Resources
    ABOUT CHRONIC
                                                                                                56 MARKETPLACE
    FATIGUE SYNDROME                                                                             + Career Opportunities &
    Research shows that the condition,                                                              Continuing Education
    once ridiculed as imaginary, is a true
    physiological disease. Here’s what
                                                                                                 + Products
    to look for, and how PTs are helping
                                                                                                59 ADVERTISER INDEX
    those who have it.
                                                                                                64 BY THE NUMBERS

 32       NEXT 2017 COVERAGE
          From physical therapy’s effects at the cellular level to inspiring stories
          of resilience after the Boston Marathon bombing, the 2017 NEXT
          Conference & Exposition brought it all. PT in Motion magazine’s
          conference coverage recaps some of those events.

COLUMNS

8   COMPLIANCE
    MATTERS
Here’s what PTs and PTAs
                               12       ETHICS IN
                                        PRACTICE
                                A PT is asked to alter a
                                                                62        DEFINING
                                                                          MOMENT
                                                                 A veteran’s career path is
should know about local         treatment schedule. Is more      forged on the battlefield.
coverage determinations         always better?
under Medicare.

2                                            PTinMOTIONmag.org / September 2017
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
Did You Know?                                                               APTA Board of Directors

    The Medicare
                                                                                                          OFFICERS
                                                                                                            President          American Physical
                                                                                            Sharon L. Dunn, PT, PhD            Therapy Association
                                                                                                      Vice President
                                                                                    Lisa K. Saladin, PT, PhD, FAPTA            1111 N Fairfax Street
                                                                                                                               Alexandria, VA 22314-1488

     Therapy Cap
                                                                                                            Secretary
                                                                                            Roger A. Herr, PT, MPA             703/684-2782 • 800/999-2782
                                                                                                            Treasurer          ptinmotionmag@apta.org
                                                                                         Jeanine M. Gunn, PT, DPT
                                                                                               Speaker of the House
                                                                                       Susan R. Griffin, PT, DPT, MS

    January 1999
                                                                                          Vice Speaker of the House            Magazine Staff
                                                                                              Stuart Platt, PT, MSPT           Editor
                                                                                                       DIRECTORS               Donald E. Tepper
                                                                                                                               donaldtepper@apta.org
                                                                                    Susan A. Appling, PT, DPT, PhD
                                                                                                                               Associate Editor
                                                                                      Cynthia Armstrong, PT, DPT
        When the initial $1,500 annual cap                                        Anthony DiFilippo, PT, PDT, MEd
                                                                                                                               Eric Ries
                                                                                                                               ericries@apta.org
        was imposed on physical therapy and                                      Matthew R. Hyland, PT, PhD, MPA
                                                                        Sheila K. Nicholson, PT, DPT, JD, MBA, MA
                                                                                                                               Contributing News Editor
                                                                                                                               Troy Elliott
        speech-language pathology services                                                   Carolyn Oddo, PT, MS              troyelliott@apta.org
                                                                                Robert H. Rowe, PT, DPT, DMT, MHS
        provided to Medicare patients.                                                   Kip Schick, PT, DPT, MBA
                                                                                                                               Association Staff
                                                                                                                               Publisher

    3
                                                                          Sue Whitney, PT, DPT, PhD, ATC, FAPTA                Lois Douthitt
                                                                                                                               Vice President, Strategic
                                                                                        Editorial Advisory Group               Communications and Alliances
        Times the cap was delayed before                                        Charles D. Ciccone, PT, PhD, FAPTA
                                                                                       Gordon Eiland, PT, MA, ATC
                                                                                                                               Jason Bellamy
                                                                                                                               Chief Executive Officer
        going into effect January 1, 2006                                                    Chris Hughes, PT, PhD             Justin Moore, PT, DPT
                                                                                         Benjamin Kivlan, PT, MPT              Advertising Manager
        (other than a 3-month period in 2003                                          Peter Kovacek, PT, DPT, MSA
                                                                                                                               Julie Hilgenberg
                                                                                                                               juliehilgenberg@apta.org
        when the moratorium expired before                                                     Robert Latz, PT, DPT
                                                                                                                               Design
                                                                                         Jeffrey E. Leatherman, PT
        legislation reinstated it).                                                Allison M. Lieberman, PT, MSPT              TGD Communications

    March 2006
                                                                                                                               creative@tgdcom.com
                                                                                             Kathleen Lieu, PT, DPT
                                                                                  Alan Chong W. Lee, PT, DPT, PhD              Advertising Sales Office
                                                                                                 Luke Markert, PTA             Ad Marketing Group
                                                                                                                               2200 Wilson Boulevard, Suite 102-333
                                                                                   Daniel McGovern, PT, DPT, ATC
                                                                                                                               Arlington, VA 22201-3324
                                                                                       Nancy V. Paddison, PTA, BA
        When the therapy cap exceptions                                                    Tannus Quatre, PT, MBA
                                                                                                                               PRODUCT DISPLAY ADVERTISING
                                                                                                                               Jane Dees Richardson, President
        process began, enabling PTs to bill for                                    Keiba Lynn Shaw, PT, MPT, EdD
                                                                                                                               703/243-9046, ext 102
                                                                                          Nancy Shipe, PT, DPT, MS             jrichardson@admarketinggroup.com
        services that exceeded the cap.                                            Jerry A. Smith, PT, MBA, ATC/L
                                                                                                                               RECRUITMENT AND COURSE ADVERTISING

    13
                                                                                              Mike Studer, PT, MHS
                                                                                                                               Meredith Turner
                                                                                          Sumesh Thomas, PT, DPT               703/339-6948
                                                                                        Mary Ann Wharton, PT, MS               mturner@admarketinggroup.com

        Times the exceptions process to the                           ©2017 by the American Physical Therapy Association (APTA). PT in Motion (ISSN 1949-3711) is
        caps has been extended, including                             published monthly 11 times a year, with a combined December/January issue, by APTA, 1111 N
                                                                      Fairfax St, Alexandria, VA. SUBSCRIPTIONS: Annual subscription, included in dues, is $10. Single
        through 2017.                                                 copies $20 US/$25 outside the US. Individual nonmember subscription $114 US/$134 outside
                                                                      the US ($194 airmail); institutional subscription $144 US/$164 outside the US ($224 airmail). No

    $1,980
                                                                      replacements after 3 months. Periodicals postage paid at Alexandria, VA, and additional mailing
                                                                      offices. POSTMASTER: Please send changes of address to PT in Motion, APTA Member Services, 1111
                                                                      N Fairfax St, Alexandria, VA 22314-1488; 703/684-2782. Available online in HTML and a pdf format
                            Therapy cap                               capable of being enlarged for the visually impaired. To request reprint permission or for general
                                                                      inquiries contact: ptinmotionmag@apta.org.
        threshold for 2017. Threshold for the
        automatic exceptions process is $3,700.                                                                    DISCLAIMER: The ideas and opinions expressed in PT
                                                                                                                   in Motion are those of the authors, and do not necessarily
                                                                                                                   reflect any position of the editors, editorial advisors, or the
                                                                                                                   American Physical Therapy Association (APTA). APTA
        Source: History of Medicare Therapy Caps webpage.
                                                                                                                   prohibits preferential or adverse discrimination on the
             American Physical Therapy Association. https://www.                                                   basis of race, creed, color, gender, age, national or ethnic
             apta.org/FederalIssues/TherapyCap/History/.              origin, sexual orientation, disability, or health status in all areas including, but not limited to, its
                                                                      qualifications for membership, rights of members, policies, programs, activities, and employment
                                                                      practices. APTA is committed to promoting cultural diversity throughout the profession.
                                                                      ADVERTISING: Advertisements are accepted when they conform to the ethical standards of APTA.
                                                                      PT in Motion does not verify the accuracy of claims made in advertisements, and publication of an
                                                                      ad does not imply endorsement by the magazine or APTA. Acceptance of ads for professional devel-
                                                                      opment courses addressing advanced-level competencies in clinical specialty areas does not imply
                                                                      review or endorsement by the American Board of Physical Therapy Specialties. APTA shall have the
                                                                      right to approve or deny all advertising prior to publication.

                                                                                                           APTA is committed to being a good steward of the environment.
                                                                                                           PT in Motion is printed using soy-based inks as defined by the
                                                                                                           American Soybean Association, is packaged using recyclable
                                                                                                           film, and uses Cadmus Communications, a Forestry Stewardship
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                                                                                                           compounds).

4                                                   PTinMOTIONmag.org / September 2017
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
Viewpoints
                                                                 PT in Motion welcomes your opinions. We will consider
                                                                 letters, email, and posts that relate to specific articles in
                                                                 the magazine and those of general interest to the physical
                                                                 therapy profession.

      Online Comments

In addition to writing to the editor, PT
in Motion readers share comments
online. Here’s a sampling of their            First Choice for a Second Career
responses to stories in the July 2017         About PTAs who began their work lives in a different career but were drawn
issue of the magazine.                        to physical therapy

                                              Shout out to the “seasoned” professionals like me! I’m soon to be 39, and
                                              my son and I will graduate next spring. He will celebrate the end of high
                                              school, and me the successful completion of a PTA program. It’s no joke
                                              being an older student. I have to work super hard, but it is worth it. All that
                                              problem solving keeps the mind sharp.

    Keeping Pain Out of the                   Posted by Megan Fitzgerald

    Red Zone
                                              Thank you for an excellent article profiling my PTA peers! I also chose
    About the latest thinking on the          the field as a second career, returning to school at 43 after a knee injury
    physical and psychological mecha-         rehab experience and my youngest son’s entering high school. I love my
    nisms of chronic pain                     rewarding career treating pediatric patients and their families, as well as
                                              mentoring current and future PT and PTA students. I forwarded this article
                                              to my new daughter-in-law (just married to that same youngest son!) as she
    Recently my husband and I were            is deciding between PT and PTA school when she completes her service as
    having this very discussion: How          an Army officer in 18 months.
    could we determine if the (chronic)
    pain a family member was report-          Posted by Kathy Gamble
    ing as “so bad, it’s never been this
    bad” was true pain or not? This
    article could not have come at a
    better time. We will definitely read
    it with great interest and in great                                    Defining Moment: Amputation
    detail.
                                                                           and Ambulation
    Posted by Celeste Dunlap
                                                                           Member Toran MacLeod, PT, PhD, recounts his
                                                                           decision to become a physical therapist.
    How would you relate this research
    to situations in which there actually
    is ongoing tissue damage, such as                                      I wish my brother had lived long enough to have
    osteoarthritis and stenosis?                                           your care. You are a great one, Toran.
    Posted by Elizabeth Neilson                                            Posted by Kay Ashbrook

       MAIL PT IN MOTION                       EMAIL PTINMOTIONMAG@APTA.ORG             In all correspondence, please include
		 1111 North Fairfax Street                FACEBOOK WWW.FACEBOOK.COM/APTAFANS
                                                                                        your full name, city, and state.
		 Alexandria, Virginia 22314-1488                                                      Letters and posts may be edited for clarity,
                                             TWITTER @APTATWEETS
                                                                                        style, and space. Published letters and com-
                                                                                        ments do not necessarily reflect the positions
                                                                                        or opinions of PT in Motion or the American
                                                                                        Physical Therapy Association.

6                                            PTinMOTIONmag.org / September 2017
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
PTinMOTIONmag.org / September 2017   7
PTs and Chronic Fatigue Syndrome - NEXT 2017 Coverage On the Menu: Nutrition-Related Physical Therapist Services - APTA
Compliance
    Matters                                       By Kyle Levin, JD

Local Coverage Determinations
Under Medicare
Here’s what PTs and PTAs should know about the process.
                              Many physical therapists (PTs) and                         records for selected claims,
                                                                                         and coordinating with CMS
                              physical therapist assistants (PTAs)                       and other contractors. In
                              know the names Noridian Healthcare                         this column, however, let’s
                                                                                         take a closer look at MACs’
                              Solutions, Novitas Solutions, and Cahaba                   role in making local cover-
                              Government Benefit Administrators.                         age determinations (LCDs).

                              They are 3 of the largest Medicare                         The ABCs of LCDs
       Kyle Levin, JD, is a
                              Administrative Contractors, or MACs—                       Simply put, an LCD is a
         regulatory affairs                                                              MAC’s decision to cover a
        specialist at APTA.
                              private health insurers that have been                     particular service or not.
                              awarded contracts from the Centers for                     Section 1869(f)(2)(B) of the
                                                                                         Social Security Act states,
                              Medicare and Medicaid Services (CMS)                       “[T]he term ‘local coverage
                              to process claims for Medicare parts A                     determination’ means a
                                                                                         determination by a fiscal
                              and B services and for durable medical                     intermediary or a carrier
                              equipment (DME) for Medicare fee-for-                      under part A or part B,
                                                                                         as applicable, respecting
                              service beneficiaries. MACs are granted                    whether or not a particular
                              jurisdiction over defined service areas,                   item or service is covered
                                                                                         on an intermediary- or
                              with 12 MAC jurisdictions for Medicare                     carrier-wide basis under
                              parts A and B processing and 4 MAC                         such parts … .”1 The Act fur-
                                                                                         ther requires that the LCD
                              jurisdictions for DME.                                     consider only “reasonable
                              In addition to processing    in the Medicare program,      and necessary” conditions
                              claims, MACs provide ser-    handling redetermination      of coverage.
                              vices that include making    requests, educating provid-
                                                                                         While the statute gives
                              and accounting for pay-      ers about billing require-
                                                                                         MACs significant latitude
                              ments, enrolling providers   ments, reviewing medical

8                                        PTinMOTIONmag.org / September 2017
in deciding whether to            All new LCDs are subject       advantage of the opportu-
cover a service, they do          to a notice and comment        nity to provide feedback on
not have carte blanche. If a      period. A notice and com-      the LCD is critical, as LCDs
national coverage determi-        ment period also is required   dramatically affect patients’
nation (NCD) is in place,         for any adapted LCD that       access to appropriate care
MACs cannot deny cover-           is more restrictive than, or   as well as reimbursement to
age of services contained         substantially changed from,    providers. While MACs are
within it. An NCD is a CMS        its predecessor. During        free to create their policies
determination of services         the notice and comment         within the boundaries of
that Medicare will cover          period, the LCD is publicly    existing NCDs, APTA has
nationally. If an NCD does        displayed—typically both       found that they will con-
not specifically mention          in the Medicare coverage       sider evidence-based argu-
coverage of a service, it is      database of CMS’s website      ments for specific changes
up to the MAC to deter-           and on the website of that     in an LCD. The association
mine whether to create an         particular MAC.                therefore embraces this
LCD to cover it.                                                 opportunity to submit
                                  Each MAC has a carrier         comments on LCDs that
Creation of an LCD occurs         advisory committee com-        affect the physical therapy
in stages and is governed by      prising members of the         community.
Chapter 13 of the Medicare        medical community who
Program Integrity Manual. 2       advise the MAC on LCDs.        After the 45-day public
If a MAC has created an           The comment period begins      comment period ends, the
LCD, other MACs may adopt         once the document has been     comment review period
it for their own jurisdictions.   distributed to this commit-    begins. During this time,
If no policy exists, or if an     tee and to other members of    the MAC’s medical director
existing policy cannot be         the medical community.         and staff review all received
adapted to the situation at                                      comments, formulate
hand, MACs may draft their        CMS mandates that the          responses, and, as they deem
own LCDs based on their           comment period be at least     appropriate, make changes
review of the medical litera-     45 days, to allow enough       to the LCD.
ture and their understanding      time for members of the
of local practice.                public to voice their opin-    Next is the notice period.
                                  ions about the LCD. Taking     The finalized LCD is posted

                                              PTinMOTIONmag.org / September 2017                 9
Compliance
     Matters

                                              Acronyms

                                              CMS: Centers for Medicare and Medicaid Services
                                              DME: Durable Medical Equipment
                                              LCD: Local Coverage Determination
                                              MAC: Medicare Administrative Contractor
                                              NCD: National Coverage Determination

                                              the MAC to revise the active      know how to bring import-
                                              LCD. The stakeholder details      ant issues to the MAC’s
                                              perceived deficiencies and        attention.
                                              proposes appropriate correc-
                                              tions. The level of evidence      To determine your MAC
              to the MAC’s website and        required for reconsideration      jurisdiction, visit the CMS
              the Medicare coverage           is the same as that required      website at www.cms.gov/
              database. The LCD is not yet    for creation of a new LCD.        Medicare/Medicare-
              active, however. Providers                                        Contracting/Medicare-
              have 45 days to familiarize     The MAC then has 30 days          Administrative-Contractors/
              themselves with the LCD         to rule on the request’s          Who-are-the-MACs.
              before it is implemented. If    validity. If it’s deemed valid,   html#MapsandLists.
              the MAC or CMS does not         the LCD is modified accord-
                                              ingly, and an explanation of      To consult the Medicare
              extend the notice period, the
                                              the changes is incorporated       coverage database—where
              LCD becomes active on the
                                              into the LCD’s language. If,      you can review draft,
              46th day. It then remains
                                              conversely, the request is        active, and retired LCDs,
              active until it is retired.
                                              deemed invalid, the MAC           as well as all NCDs—go to
              Although the LCD is active,     has 90 days to outline its        www.cms.gov/medicare-
              opportunities remain to         rationale for the decision.       coverage-database/
              modify it should issues arise                                     overview-and-quick-search.
                                                                                aspx?list_type=ncd.
              that were not foreseen prior    Resources
              to activation. In some cases,
                                              Those are the basics of the       REFERENCE
              for example, the finalized
              LCD excludes certain ser-       LCD process. APTA seeks           1. Social Security Administration.
                                                                                     Compilation of the Social Security
              vices that actually are cov-    to change LCDs as needed               Laws. https://www.ssa.gov/
              ered by an NCD, or the LCD      while they are in draft form           OP_Home/ssact/title18/1869.htm.

              is demonstrably inefficient     and to modify them when                Accessed June 29, 2017.
                                              necessary through the             2. Centers for Medicare and Medicaid
              toward or prejudicial to the                                          Services. Medicare Program
              physical therapy profession.    reconsideration process.              Integrity Manual Chapter 13—
              In such instances, APTA and     But it’s also important for           Local Coverage Determinations.
                                              clinicians to understand              https://www.cms.gov/Regulations-
              other applicable stakehold-                                           and-Guidance/Guidance/
              ers seek an “LCD reconsid-      the determination process             Manuals/downloads/pim83c13.
              eration”—a written request to   to ensure that they have all          pdf. Accessed June 29, 2017.
                                              necessary information and

10                        PTinMOTIONmag.org / September 2017
PTinMOTIONmag.org / September 2017   11
Ethics in Practice                                    By Nancy R. Kirsch, PT, DPT, PhD

 Is More Always Better?
 Or is twice sometimes nice?

                                       In an era in which budgetary consider-                          Shortly after a regional
                                                                                                       VA administrator's visit to
                                       ations and productivity concerns can                            his facility, Luke’s director
                                       influence clinical practice, physical ther-                     calls a department meeting
                                                                                                       and makes an announce-
                                       apists (PTs) aren’t accustomed to being                         ment: She wants him and
                                       directed to increase their time with                            the other PTs on staff to
                                                                                                       see all patients with mus-
                                       patients. But what might seem like a                            culoskeletal issues 3 times
  Nancy R. Kirsch, PT, DPT, PhD,
                                       good problem to have can have a down-                           per week. “I know from the
 a former member of APTA’s Ethics                                                                      monthly numbers that some
      and Judicial Committee and a     side. Consider the following scenario.                          of you sometimes are seeing
   Catherine Worthingham Fellow                                                                        patients less frequently,” she
                                       Travel Bane                     or logistical burden to         says. “When our regional
  of the American Physical Therapy                                     those who drive them.
                                       Luke is a PT at a Veter-                                        administrator was in town,
         Association, is the program                                                                   we got to talking, and we
                                       ans Administration (VA)         Luke’s solution has been,
director and a professor of physical   facility in a rural area that                                   determined that best prac-
                                                                       in some cases, to reduce
       therapy at Rutgers University   serves a large geographic       visit frequency from 3          tice argues for standardiz-
    in Newark. She also practices in   region. Luke enjoys the         times a week to 2. He           ing the number of weekly
              northern New Jersey.     work—especially the satis-      has studied the literature      visits for these patients at
                                       faction of helping individ-     and has determined that,        3. Because they are in the
                                       uals who have served their      for the musculoskeletal         VA system, this won’t place
                                       country to be as mobile and     issues that bring some of       a financial burden on them,
                                       active as possible.             his patients to the facility,   and we’ll be better able to
                                                                       there’s no significant ben-     ensure that they’re getting
                                       Getting to the VA center                                        the best possible care from
                                                                       efit to a third weekly visit
                                       is a hardship for many of                                       us. It’s a win-win situation.”
                                                                       as long as he has maxi-
                                       Luke’s patients. They often
                                                                       mized the other visits and      Luke raises his hand and
                                       must travel great distances,
                                                                       has provided the patient        says, “Won’t that increase
                                       which may impose a phys-
                                                                       with a strong home exer-        the travel burden for some
                                       ical burden if they drive
                                                                       cise program.                   patients?”
                                       themselves, or a financial

 12                                                PTinMOTIONmag.org / September 2017
“Perhaps a bit,” Mary           the fact that federal fund-
acknowledges. “But as           ing shortages have forced
we all know, veterans are       the closure of some VA
determined and resourceful      facilities?”
people. Ensuring that we’re
providing them with the         “Absolutely not!” Mary
highest quality care must       exclaims. “This is entirely a
be our first priority.”         patient-centered decision.”

Luke then notes that the        Luke has been given a                   resources
literature suggests that        directive, so he implements
equally efficacious results     it with the patients he’s        At www.apta.org/Policies/Practice/
can be achieved, in many        been seeing twice weekly.
                                “Think of it as an added         kk Standards of Practice for Physical Therapy
cases, with 2 weekly visits
rather than 3. A couple         layer of care,” he tells them.
                                                                 At www.apta.org/EthicsProfessionalism/
of his colleagues nod           “And,” he self-deprecat-
affirmatively.                  ingly adds, “You get to see      kk Core ethics documents (including the Code of
                                more of me each week for            Ethics for the Physical Therapist and Standards
“With due respect,” Mary        the duration of the care epi-       of Ethical Conduct for the Physical Therapist
replies, “I know what the       sode—an added bonus!”               Assistant)
research says, and the
evidence is there for this      For a while, Luke complies       kk Ethical decision-making tools (past Ethics in
change.” She cites as exam-     with Mary’s directive. But          Practice columns, categorized by ethical principle
ples a pair of studies with     soon, some of his patients          or standard; the Realm-Individual Process-Situation
which Luke is familiar—nei-     start asking him to please          [RIPS] Model of Ethical Decision-Making; and
ther of which strike him as     go back to a twice-weekly           opinions of APTA’s Ethics and Judicial Committee)
definitive or particularly      visits schedule, because the
                                extra driving each week—         At www.apta.org/PTinMotion/2006/2/
compelling.                                                      EthicsinAction/
                                200 miles or more round-
At that point another PT,       trip in some cases—is            kk “Ethical Decision Making: Terminology and
Stella, asks, “Is this move     proving to be burdensome.           Context”
at all related to our overall   At first, Luke holds his
utilization numbers, and        ground. But then he starts

                                             PTinMOTIONmag.org / September 2017                                           13
Two
     Column
     Ethics in Practice

                                                                                               relenting on a case-by-case
                                                                                               basis, confident that the
     Considerations and Ethical Decision-Making                                                literature backs him up
                                                                                               and certain that, should
     Luke has been asked to alter a treat-        barrier—Mary’s opposition—to continu-        Mary challenge him, he
     ment schedule that he’s worked out           ing on that course, this is an ethical       can compellingly justify his
     with a number of his patients based on       distress for the PT.                         decision.
     the ethical principle of beneficence—
     doing what is best for the patient,          Ethical principles. The following            It doesn’t take long for this
     based on his or her presentation             principles of the Code of Ethics for         pushback to come. At the
     and specific needs. He does not feel         the Physical Therapist offer Luke            end of the first month that
     that the mandated alteration models          guidance:                                    Luke has gone back to see-
     beneficence. He’s not even certain                                                        ing several patients twice
                                                  kk Principle 2D. Physical therapists
     that his director believes the revised                                                    weekly, Mary takes him
                                                     shall collaborate with patients/
     treatment schedule really is necessary                                                    aside and says, “The latest
                                                     clients to empower them in deci-
     from a patient-care standpoint. Still, he                                                 statistical report shows
                                                     sions about their health care.
     is expected to comply or perhaps face                                                     that your visit numbers
     consequences. This places him in an          kk Principle 3A. Physical therapists         are notably down. What’s
     ethical bind.                                   shall demonstrate independent and         going on?”
                                                     objective professional judgment in
     Realm. The ethical realm here is                                                          Luke starts to explain his
                                                     the patient’s/client’s best interest in
     organizational. Mary has given Luke a                                                     rationale by talking about
                                                     all practice settings.
     directive that she presents as benef-                                                     the travel hardships and
     icent, but it seems to Luke not to be        kk Principle 7A. Physical therapists         citing relevant research
     in the best interests of several of his         shall promote practice environ-           studies, but Mary quickly
     patients.                                       ments that support autonomous             shuts him down. “More
                                                     and accountable professional              treatment, better results, no
     Individual process. Moral judgment              judgments.                                additional cost to patients,”
     is required of Luke, in that he feels he                                                  she says. “What is it about
     has identified a right and wrong action      kk Principle 8C. Physical therapists         this policy that you don’t
     and must decide which position to               shall be responsible stewards of          understand?”
     stand behind.                                   health care resources and shall
                                                     avoid overutilization or underutili-      He wants to believe that
     Ethical situation. Because Luke                 zation of physical therapy services.      her motives are honorable
     feels strongly that he knows the right                                                    and that this isn’t about
     course of action but faces a structural                                                   physical therapy utilization
                                                                                               above all else. But even
                                                                                               if that’s the case, Luke

14                                             PTinMOTIONmag.org / September 2017
believes that Mary is wrong      proposed frequency and
on the science, and that         duration, and implemen-
the needs of the individual      tation of the plan of care.”
patient must be paramount        Consider that sentence in
in any treatment plan.           the context of the pre-
                                 sented scenario.
“Look,” Mary continues in
a more conciliatory tone,
                                 For Followup
“I understand where you’re
coming from. Getting here        I encourage you to share
is a hike for many of our        your thoughts about the
vets. I feel bad about that,     issues raised in this sce-
but there’s no changing the      nario by emailing me at
geography. All we can do is      kirschna@shp.rutgers.edu
serve these patients the best    or by posting a comment
way we know how. Okay?”          online.

Luke knows what the ques-        If you are reading the print
tion really means: “Are you      version of this column,
down with the program, or        go online to www.apta.
not?” He knows, too, that        org/PTinMotion/2017/9/
his answer has implications      EthicsinPractice/ for
for patient care and his         a selection of reader
own sense of integrity. He       responses to the scenario
considers his response.          and my thoughts on those
                                 responses. Scroll down
For Reflection                   to the heading “Author
                                 Afternote.”
Standards of Practice for
Physical Therapy (see            Be aware, however, that
resources box on page            it takes a few weeks after
13 for the link) cites the       initial print and online
elements of PTs’ plan of         publication for feedback to
care. It states, in part, “The   achieve sufficient volume
physical therapist involves      to generate this online-
the patient/client … in the      only feature.
planning, anticipated goals
and expected outcomes,

                                             PTinMOTIONmag.org / September 2017   15
The Real Story About
     Chronic Fatigue
     Syndrome

16          PTinMOTIONmag.org / September 2017
Research shows that the              Chronic fatigue syndrome (CFS)       get off your own back, and wrap
                                     has come a long way since the        your head around this.”
condition, once ridiculed            1980s, when it was widely dis-
                                                                          “What do you do with that?” she
  as imaginary, is a true            missed as “yuppie flu” and was
                                                                          asks. “I decided that I needed to
                                     suspected by many health care
   physiological disease.            providers of being a psycholog-      figure out how to manage this on
                                                                          my own.”
                                     ical rather than a physiological
  Here’s what to look for,           condition.                           As luck or fate would have it, she
and how PTs are helping              (A note on terminology: CFS goes     soon happened upon—literally
                                                                          dragged herself to—a symposium
       those who have it.            by at least 3 names, per the side-
                                     bar on page 20. As CFS remains       on CFS at an APTA Combined
                                     the one by which the illness most    Sections Meeting. What Rabanal

          By Eric Ries               widely is known, that’s the term     learned that day in Anaheim,
                                     PT in Motion is using.)              California, led her to a treatment
                                                                          relationship with the Salt Lake
                                     Nicole Rabanal, PT, was among        City-based Bateman Horne
                                     the skeptics. Until late 2014 she    Center, which specializes in CFS
                                     considered “chronic fatigue          and fibromyalgia.
                                     syndrome” to be “a catch-all term
                                     that meant medical science didn’t    Today, her life is “all about pacing
                                     know what the patient had or         and management.” Rabanal, who
                                     didn’t have.”                        owns Kinetic Energy Physical
                                                                          Therapy in Steamboat Springs,
                                     She changed her mind the             Colorado, describes her highly
                                     morning she woke up “feeling,        regimented routine.
                                     out of the blue, like I’d been hit
                                     by a truck—with severe flu-like      “I work a 2-hour shift in the morn-
                                     symptoms, severe eye pain,           ing,” she says. “I come home and
                                     headache, ‘heavy’ head, muscle       lie down in a quiet room—with
                                     weakness, random numbness and        oxygen, and with ice on my eyes
                                     tingling sporadically throughout     and head—for 4 hours. I go back
                                     my body, and difficulty breathing    to work for another 2-hour shift.
                                     and swallowing.” This sudden         I return home to again lie down
                                     and dramatic shift in the then-      with ice and oxygen. I get up and
                                     46-year-old’s health led her on      have dinner with my family, and
                                     a year-long odyssey through          am in bed no later than 8 pm.”
        NICOLE RABANAL
                                     the health care system, during       On weekends, she continues, “I
                                     which she saw 17 specialists and     stay quiet all day, either lying
                                     was at various times told she        down or resting. On Sunday, I
                                     had depression, Lambert-Eaton        might get out and do something
                                     myasthenic syndrome, and             with my kids for an hour. But
                                     myasthenia gravis.                   that’s it. There’s no going out to
                                     When her fifth neurologist at        eat, and only minimal socializing
                                     last hit the nail on the head—       with friends because prolonged
                                     CFS is a diagnosis of exclusion      talking is very draining for me.
                                     for which there is no test—he        I have significant sensitivity to
        BECKY VOGSLAND                                                    light and sound, which greatly
                                     told her, “Stop doctor-shopping,
                             PTinMOTIONmag.org / September 2017                                             17
Rabanal has a message for her             that CFS has a physiological
                                                       fellow PTs.                               basis—albeit an ill-defined one—and
      “Typically you’re seeing patients
                                                                                                 that it is a “serious, chronic, com-
     based on their referral label being               “We must know the criteria for            plex, systemic disease that often
                                                       patients to meet this diagnosis—sig-
            only part of the condition.”               nificant reduction or impairment in
                                                                                                 can profoundly affect the lives of
                                                                                                 patients” and “requires timely and
                     – TODD DAVENPORT                  ability to engage in pre-illness activ-   appropriate care.”
                                                       ity levels, accompanied by fatigue,
           limits the surroundings in which I          for more than 6 months; post-exer-        CFS affects between 836,000 and
           place myself.”                              tional malaise; unrefreshing sleep;       2.5 million Americans, according to
                                                       and either cognitive impairment or        the Centers for Disease Control and
           The upside, if you want to call it          orthostatic intolerance. Because if       Prevention (CDC). But that’s really
           that, has been the demonstrated             we aren’t correctly identifying this      only a guess, the agency concedes,
           value of Rabanal’s professional             patient population, it’s easy to push     as “an estimated 84% to 91% of
           training.                                   patients into a treatment or exer-        people with CFS have not been
                                                       cise program that will make their         diagnosed. 2
           “The knowledge and experience
                                                       condition worse. They are likelier
           of having been a PT for nearly 25                                                     What causes it? This also is
                                                       to be noncompliant, disinclined to
           years has been incredibly helpful                                                     hazy. As APTA summarizes in
                                                       follow up with care, and present as
           to my personal treatment plan,”                                                       its consumer-oriented “Physical
                                                       a returning patient whose condition
           Rabanal says. “Listening for and                                                      Therapist’s Guide to Chronic
                                                       never seems to improve.”
           understanding the signs of when                                                       Fatigue Syndrome, 3 “Many
           I’m pushing beyond my energy                There is a great deal that PTs can        researchers suspect impairment
           limitations, then implementing              do to help patients with CFS of all       of the aerobic energy, immune,
           appropriate exercise and stretching,        severity levels, say those who PT in      and gastrointestinal systems may
           is a big part of the management             Motion contacted for this article. It     be responsible for the functional
           puzzle. This of course is what PTs          begins with listening and a thor-         impairment experienced in indi-
           do every day with patients, in one          ough patient interview and extends        viduals with this condition.” The
           form or another—we listen closely           through education, individualized         Mayo Clinic advises that CFS may
           and apply our knowledge to their            goal-setting, pacing, movement and        be caused by “a combination of
           presentation and what we learn              strengthening exercises, manual           factors that affect people who were
           from them.”                                 therapy, and appropriate referral.        born with a predisposition to the
                                                                                                 disorder.”4 Factors that have been
           “I’ve made significant modifications        What PTs can offer, too, is what          studied, Mayo notes, include viral
           to my treatment style,” Rabanal             people with CFS arguably need the         infections, immune system disor-
           adds. “I sit a lot, and lean or move        most, says Jessie Podolak, PT, DPT,       ders, and hormonal imbalances.
           to help manage my orthostatic               owner of Phileo Health in Altoona,
           intolerance—which does not allow            Wisconsin, and a certified therapeu-      Todd Davenport, PT, DPT, MPH,
           me to stand still, unsupported, for         tic pain specialist. “We can bring        edited the APTA consumer guide
           more than 5 minutes. I co-treat with        them hope.”                               to CFS and has conducted research
           other therapists in my clinic to per-                                                 on the disease. He also long has
           form manual techniques that I no
           longer can do because of my limited         Putting 2 and 2                           been active with the Workwell
                                                                                                 Foundation—a Ripon, California,
           strength. During my work periods, I
           use a Fitbit to monitor my heartrate
                                                       Together                                  based nonprofit that researches
                                                                                                 functional aspects of the disease
           and its silent timer to remind me           A turning point for those facing
                                                                                                 and conducts cardiovascular and
           when take my medications.”                  CFS came in 2015, when the
                                                                                                 pulmonary exercise testing to
                                                       Institute of Medicine issued an
                                                                                                 determine and document postex-
           “It’s a huge challenge,” she says.          extensively researched report on
                                                                                                 ertional malaise and symptom
           “But I love what I do, so I’m deter-        the disease subtitled “Redefining
                                                                                                 exacerbation after physical activity.
           mined to make it work.”                     an Illness.”1 It firmly established

18                                                PTinMOTIONmag.org / September 2017
The Basics
                                          DESCRIPTION
                                          Chronic fatigue syndrome (CFS) is a devastating and complex disorder. People
                                          with CFS have overwhelming fatigue and a host of other symptoms that are
                                          not improved by bed rest and that can worsen after physical activity or mental
                                          exertion. They often function at a substantially lower level of activity than they
                                          were capable of before they became ill.
                                          Besides severe fatigue, other symptoms include muscle pain, impaired mem-
Per the CDC’s figures on diagnosis,
                                          ory or mental concentration, insomnia, and postexertion malaise lasting more
it is atypical, Davenport notes, for
                                          than 24 hours. In some cases, CFS can persist for years.
PTs to get patients who’ve been
referred by physicians with a             Researchers have not yet identified what causes CFS, and there are no tests to
diagnosis of CFS.                         diagnose CFS. Moreover, because many illnesses have fatigue as a symptom,
                                          doctors need to take care to rule out other conditions, which may be treatable.
“Typically you’re seeing patients
based on their referral label being       www.cdc.gov/cfs/general/index.html
only part of the condition,” says
Davenport, an associate profes-           PREVALENCE
sor and program director of the           CFS affects 836,000 to 2.5 million Americans. An estimated 84%–91% of people
Department of Physical Therapy            with CFS have not been diagnosed, meaning the true prevalence is unknown.
at the University of the Pacific          CFS affects women more often than men. The average age at onset is 33, but it
in Stockton, California, and a            has been reported in patients younger than 10 and older than 70.
board-certified clinical specialist in
orthopaedic physical therapy. “So,        www.nap.edu/read/19012/chapter/1
the referral may be for ‘widespread
bodily pain.’ Or, perhaps the patient     DIAGNOSTIC CRITERIA
has noticed a functional decline          Diagnosis requires that the patient have 1 of the following 3 symptoms:
and has been talking to his or her
primary care physician about a            1. A substantial reduction or impairment in the ability to engage in pre-ill-
fatigue issue. That individual, then,        ness levels of occupational, educational, social, or personal activities that
may be referred with a diagnosis of          persists for more than 6 months and is accompanied by fatigue, which is
deconditioning.”                             often profound, is of new or definite onset (not lifelong), is not the result of
                                             ongoing excessive exertion, and is not substantially alleviated by rest,
It’s imperative on the PT, therefore,
“to put 2 and 2 together—to deter-        2. Postexertional malaise,* and
mine whether the patient may have         3. Unrefreshing sleep.
CFS and might, therefore, require
appropriate management strate-            At least 1 of the 2 following manifestations also is required:
gies,” Davenport says.
                                          1. Cognitive impairment* or
One of the stated aims of an
                                          2. Orthostatic intolerance.
analysis that Davenport and his
Workwell colleagues published in          *Frequency and severity of symptoms should be assessed. The diagnosis of ME/CFS should
Physical Therapy in 20105 was to          be questioned if patients do not have these symptoms at least half of the time with moderate,
                                          substantial, or severe intensity.
discuss aerobic system deficits that
may lead to the clinical presentation     www.nap.edu/read/19012/chapter/1
of CFS. “Where the literature seems
                                          Seeking and receiving a diagnosis can be a frustrating process for several
                                          reasons, including skepticism of health care providers about the serious nature
                                          of CFS and the misconception that it is a psychogenic illness or even a figment
                                          of the patient’s imagination. Less than one-third of medical schools include
                                          CFS-specific information in the curriculum, and only 40% of medical textbooks
                                          include information on the disorder. It often is seen as a diagnosis of exclusion,
                                          which also can lead to delays in diagnosis, or to misdiagnosis of a psycholog-
                                          ical problem. Once diagnosed, patients frequently complain that their health
                                          care providers do not know how to deliver appropriate care for their condition
                                          and often subject them to treatment strategies that exacerbate their symptoms.
  JESSIE PODOLAK                          www.nap.edu/read/19012/chapter/2

                                         PTinMOTIONmag.org / September 2017                                                               19
That’s What She SEID (About the Name)
“Trivializing.” “Stigmatizing.” “A disservice to many                              The words “systemic exertion intolerance disease” do
patients.” “Does not accurately describe the major features                        not exactly roll off the tongue, agrees Nicole Rabanal, PT.
of the disease.”                                                                   Nevertheless, she personally has experienced the new
                                                                                   name’s ability to positively alter perceptions.
Those are some of the ways the Health and Medicine
Division of the National Academies of Science,                                     Rabanal, who owns Kinetic Energy Physical Therapy in
Engineering, and Medicine (formerly the Institute of                               Steamboat Springs, Colorado, was diagnosed in late 2014
Medicine), in a highly publicized 2015 report, character-                          with CFS, an illness that has greatly circumscribed her
ized the name of the medical condition commonly known                              personal and professional life. Nevertheless, she says,
as chronic fatigue syndrome (CFS).                                                 “When people ask me, ‘What’s wrong with you? Did they
                                                                                   ever figure it out?’ and I say, ‘I have chronic fatigue,’ they
Ronald Davis, PhD, a biochemist who heads the Genome                               pat me on the shoulder and say, ‘Oh, you’ll be okay. Just lie
Technology Center at Stanford University, hit on the crux of                       down and rest.’”
the problem in an interview with Science magazine after the
report’s release. “My son is sick with [CFS], and when I tell                      Such reactions, she says, are “devastating—the stigma is
people, they say, ‘I had that once’ because they were tired                        horrible.” But when Rabanal instead replies that her diag-
once,” a frustrated Davis remarked.1                                               nosis is an illness called systemic exertional intolerance
                                                                                   disease, the response is, “My gosh, that’s awful! What can
The disease also sometimes is called myalgic encephalo-                            I do for you? How can I help you?”—even though it’s clear
myelitis (ME), CFS/ME, or ME/CFS. “ME is a better name,”                           that the questioner hasn’t a clue what the term means.
Davis told the magazine—but, he observed, “there are no                            Sometimes a simple lack of pejorative association makes all
real data to fit [it].”                                                            the difference.
Davis was on the committee that compiled the 2015 report,                          The trick going forward, Rabanal says, will be to teach
titled “Beyond Myalgic Encephalomyelitis/Chronic Fatigue                           both the public and still-skeptical members of the medical
Syndrome: Redefining an Illness.”2 After reviewing more                            community that a condition they may underappreciate or
than 9,000 scientific studies, weighing expert testimony,                          even dismiss under the CFS/ME moniker is one and the
and soliciting public input, the panel concluded not only                          same with the scientifically validated disease that more
that “ME/CFS is a serious, chronic, complex, and systemic                          accurately has been rechristened SEID.
disease that frequently and dramatically limits the activities
of affected patients” and that merits new diagnostic criteria,                     “If you can’t make that connection, there’s no validation for
but also that the words commonly used to describe the                              the thousands upon thousands of people who are afflicted
illness are offensive in the case of chronic fatigue syndrome                      with this disease,” Rabanal argues. “This patient population
and inaccurate in the case of myalgic encephalomyelitis.                           has to be validated in its suffering, which can be extensive.
                                                                                   Education is the only way to do that.”
Regarding ME, the report read, “The committee concludes
that the term ‘myalgic encephalomyelitis’ is inappropriate                         “Names change all the time,” observes Adriaan Louw, PT,
because there is a lack of evidence for encephalomyelitis                          PhD. He has worked clinically with people with chronic pain
(brain inflammation) in ME/CFS patients, and myalgia                               for 25 years and is president of the International Spine and
(muscle pain) is not a core symptom of the disease.”                               Pain Institute. What’s most important for PTs to do, Louw
                                                                                   says, is encapsulated in the title of a presentation he gave
The new term the panel chose to describe the illness was                           in February at APTA’s Combined Sections meeting in San
“systemic exertion intolerance disease,” or SEID. “This                            Antonio, Texas.
name,” the panelists wrote, “captures a central characteris-
tic of the disease: the fact that exertion of any sort—physical,                   In that talk, which focused on how PTs best can understand
cognitive, or emotional—can adversely affect patients in                           CFS and other persistent pain disorders, Louw emphasized
many organ systems and in many aspects of their lives.”                            the need to base clinical decision-making not on general-
                                                                                   ized protocols and preconceived notions, but on the indi-
While SEID—a term that has yet to capture the public’s                             vidual’s specific presentation and information the clinician
imagination—has accuracy on its side, even Davis concedes                          has culled from extensive patient interviewing. He titled it
its descriptive flatness. “It’s hard to come up with a good                        “Treat the Patient, Not the Label.”
name, and I don’t think this is a perfect name,” he told
Science 2 years ago.

REFERENCES
1. Cohen J. Goodbye chronic fatigue syndrome, hello SEID. Science. February 10, 2015. www.sciencemag.org/news/2015/02/goodbye-chronic-fatigue-syndrome-hello-
    seid. Accessed June 19, 2017.
2. Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining and Illness. Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic
     Fatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine. Washington, DC: National Academies Press; 2015.

20                                                         PTinMOTIONmag.org / August 2017
to be relatively strong,” Davenport      he advises. “You’re going to be
says, “is in the etiology that there     seeing these patients for months
are aerobic system impairments           and years—albeit less frequently, for
in people with CFS/ME.” (“ME”            the most part, as time goes on.”
stands for myalgic encephalomy-
elitis; see the sidebar on the facing    Davenport concedes that this
page). “We’re not sure why this          “go-slow” approach can seem
is. We just know that the aerobic        counterintuitive when “exercise is
system is not as effective in these      our wheelhouse as PTs” and “a lot of
individuals.”                            forms of fatigue are seen as varia-
                                         tions on deconditioning.” Presented
This information is instructive for      with a patient who is tired, “we PTs
PTs, Davenport says. “If you start       want our exercise tool to work well.”
with the assumption that the aero-       He cautions, however, that, “We’re      “capturing quite well the complex-
bic system is impaired, that guides      employing the wrong tool for the        ity of CFS” and the importance
what PTs should do. The first step is    job if we’re pushing graded exercise    of building patient strength and
to teach patients about activity pac-    and telling patients that they just     endurance from an anaerobic
ing that will keep them within the       need to get up and get moving.”         foundation.
limits of their symptoms. We don’t       He cites as a cautionary tale the
want people going to Costco and          infamous-in-CFS-circles PACE            “When an individual gets that
then being zonked out for the rest of    study of 2011,6 which essentially       super-malaise from exertion, that
the week. So, we advocate for people     suggested that a combination of         can foster kinesiophobia, or fear of
to look at the peaks and valleys of      psychotherapy and exercise might        movement,” Keeton notes. “If you
their daily activities and saw off the   be the CFS patient’s best friends. It   can empower the patient to find
peaks—using that energy to help fill     caused an uproar in the scientific      movements that don’t trigger that,
in the valleys.”                         community over its methodology          while correlating to patient-iden-
                                         and conclusions, and was famously       tified problems and impairments
“The second step,” he continues,         eviscerated on the Virology Blog,7 a    that you’ve noted, your therapeutic
“is to train people in lower-level       popular online resource for dissem-     alliance with that patient improves,
anaerobic activities that register       ination of knowledge about viruses
under the ventilatory threshold for      and viral disease.
aerobic activation and take less
than 2 minutes. Focus on stretch-        “To me,” Davenport says, “best
ing and gentle exercise, with the        practice with this patient pop-
aid of a heartrate monitor that’s        ulation, as with all patients we
set below the ventilatory threshold      see as PTs, comes back to good,
and can alert the patient when that      old-fashioned listening—taking on
threshold has been exceeded and          good faith what the patient what
rest is needed.”                         the patient has to say, and going on
                                         from there.”
Finally, Davenport says, “the
last piece is to get patients into                                               “One of our great advantages is
longer-duration activities by way        The Power of
                                                                                 the physical connection we have
of gradually building on anaerobic
training—while recognizing that          Listening                               with our patients. We’re in a unique
the prognosis for full functional        Ben Keeton, PT, DPT, director of
recovery is very guarded and             clinical operations at The Jackson      position as PTs to add a positive
limited.” Anaerobic threshold            Clinics in northern Virginia, lauds     connotation to movement in the
training and pacing “aren’t going to     the 2010 Physical Therapy piece
                                         that Davenport lead-authored as
                                                                                 case of people with CFS.”
‘fix’ impaired aerobic metabolism,”
                                                                                 – BEN KEETON
                                                PTinMOTIONmag.org / August 2017                                         21
therapists can offer them. But it all   their chronic fatigue, so that you
                                                   starts with the patient interview,”     then can guide them toward greater
                                                   Louw says. “Ninety percent of           function and more energy.” The
                                                   our patients with chronic fatigue       owner of Zang Physical Therapy
                                                   syndrome start crying during this       in Lemoyne, Pennsylvania, he’s a
                                                   process, simply because we’re           board-certified clinical specialist in
                                                   spending time with them, taking         orthopaedic physical therapy and
                                                   them seriously, and demonstrating       a fellow of the American Academy
                                                   that we care about them as human        of Orthopedic Manual Physical
                                                   beings.” Louw, who is based in Iowa,    Therapists.
                                                   has worked clinically with people
  “I have treated these patients and               with chronic pain for 25 years and is   “Active listening by the physical
                                                                                           therapist is key,” echoes Becky
  conducted research on them, and                  president of the International Spine
                                                                                           Vogsland, PT, DPT, who coordi-
                                                   and Pain Institute, which offers
       there are so many things that               continuing education courses and        nates the Comprehensive Pain
 therapists can offer them. But it all             certifications.                         Center of the Minneapolis VA
                                                                                           Health Care System and is a
  starts with the patient interview.”              “If they don’t cry during the subjec-   board-certified clinical specialist
                    – ADRIAAN LOUW                 tive exam, they often do during the     in orthopaedic physical therapy.
                                                   physical one,” he says. “They’ll say,   “To borrow a term from our
        along with the prognosis. That’s           ‘That’s the most thorough medical       psychology colleagues, follow the
        very powerful.”                            exam I’ve had in 10 years.’”            ‘VEMA’ model: validate, educate,
                                                                                           motivate, activate.”
        Keeton, a board-certified clinical         “People who are in chronic pain
                                                   tend to look ‘normal’ to others, and
        specialist in orthopaedic physical
        therapy, adds that the value of the        often feel disbelieved and very         Achieving Goals
        “physical” part of what physical           isolated,” notes Jessie Podolak.        PTs who treat patients with CFS
        therapists do can’t be understated         “It’s huge when we encourage            must leaven their messages of
        with this patient population.              them to tell their whole story and      hope with acknowledgement
                                                   say, ‘I hear and understand you.’       that improvement likely will be
        “One of our great advantages is the        It’s important that we explain          incremental and recovery far from
        physical connection we have with           what’s happened to them in a            complete. They therefore are reluc-
        our patients,” he says. “We’re in          way that makes sense—that we            tant to recount memorable “success
        a unique position as PTs to add a          say, ‘There’s been a tipping point,     stories” without asterisks—even
        positive connotation to movement           a shift in your homeostasis, but        while acknowledging the signifi-
        in the case of people with CFS.            things will get better, and I’ll sup-   cance of relative improvements.
        Passive or assisted active range of        port you throughout the process.”
        motion, where there’s good quality                                                 Keeton cites a patient who’d expe-
        of contact and the practitioner has        “You have to be present with            rienced chronic back pain for 20
        strong manual therapy skills, builds       patients with CFS,” is how Andrew       years and had been diagnosed with
        that trust that moving won’t hurt—or       Zang, PT, DPT, puts it. “You need       CFS as a comorbid condition. “This
        at least that it won’t hurt as much.”      to learn as much as you can about       may sound underwhelming,” he
                                                   what they can and can’t do, what        says, “but at the end of 12 weeks in
        The first step in all this, according      their goals are, and what their         physical therapy her baseline pain
        to Adriaan Louw, PT, PhD, goes             perception is of why they can’t do      level was down from 6 or 7 all day
        back to Davenport’s comments               things. You almost need to be part      on a 10 scale to 3 or 4. That made
        about “old-fashioned listening.”           psychologist, to ensure that they       a big difference in her life. We
                                                   get the most out of their treatment     created a plan of care to conserve
        “I have treated these patients and
                                                   sessions. You need to help them         energy and restore mobility. We
        conducted research on them, and
                                                   understand the ‘what’ and ‘why’ of      incorporated all of the manual
        there are so many things that

22                                            PTinMOTIONmag.org / September 2017
therapy and exercise components           Podolak has been seeing a patient
necessary to manage the low               with CFS for the past 2 years who,
back pain, but we did it within the       at the outset, could walk only 50       “You need to help them understand
context of chronic fatigue—with an        feet—“if that.” He loves nature and
eye to functional activity.”              had sorely missed walking outside,      the ‘what’ and ‘why’ of their
                                          so she’s helped get him to the point    chronic fatigue, so that you then
The patient had been an avid              that he now can walk around a local
kayaker earlier in her life. “After 10                                            can guide them toward greater
                                          park for 10 minutes. “That was a
years of no kayaking, it was a pretty     very meaningful goal for him to         function and more energy.”
big celebration when she paddled          meet,” she says.
her first tenth of a mile,” Keeton                                                – ANDREW ZANG
says. “It was very rewarding for me       The next goal will be enabling him
as a PT. She’s empowered now to           to make short drives downtown and       comorbidity in this patient popula-
make her own decisions about how          decrease his isolation, Podolak says.   tion of which PTs should be aware.
to manage her exertion and budget         Socialization should help combat        If it’s present, is the patient being
her energy. What she said to me           his depression issues, she notes,       treated for it? Ask questions.”
was, ‘I either could maintain a pain      adding, “Depression is a common
level of 3 or 4 and just do my daily
life stuff, or I could maintain that
pain level, do my daily life stuff a
little bit less, and use that energy to
hit the water. I choose water.’”
Louw recalls a frank exchange
he had with a stay-at-home mom
with CFS who struggled daily with
fatigue and pain in order to meet
her family’s needs. “While her hus-
band and kids were eating dinner,
she was crying in bed by herself,”
he says.
“I explained that she must space
out her activities, take breaks, and
make other adjustments. She told
me her life was too busy to do that.
I responded, ‘You don’t have a life,’”
Louw recounts.
“I wasn’t trying to be rude,” he
emphasizes. “I just meant that the
way she was living was not the way
anyone should have to live. She
looked at me and said, ‘Wow, it isn’t
[a life].”
After making the necessary adjust-
ments, that patient ultimately was
able to enjoy dinner with her family,
while “in very little if any pain,”
says Louw.

                                               PTinMOTIONmag.org / September 2017                                         23
Resources
GENERAL
Physical Therapist’s Guide to Chronic Fatigue Syndrome
kk www.moveforwardpt.com/SymptomsConditionsDetail.aspx?cid=13f232c1-
   2d06-4063-8a3b-5ae844fdd075
Centers for Disease Control Toolkit for Providers
kk www.cdc.gov/cfs/pdf/cfs-toolkit.pdf
Mayo Clinic                                                                      The Future
kk www.mayoclinic.org/diseases-conditions/chronic-fatigue-syndrome/
                                                                                 Exactly how bright the future looks
   basics/definition/con-20022009
                                                                                 for people with CFS in terms of
Workwell Foundation: Research on Chronic Fatigue Syndrome                        finding answers through research
kk www.workwellfoundation.org/                                                   depends on who you talk to.

Bateman Horne Center for ME/CFS and Fibromyalgia                                 Louw is particularly encouraged
kk https://batemanhornecenter.org/                                               by the body of work of Belgian
                                                                                 researchers Mira Meeus and Jo
ARTICLES                                                                         Nijs, with whom he’s collaborated,
“The Tragic Neglect of Chronic Fatigue Syndrome”                                 calling them “world-leading
kk www.theatlantic.com/health/archive/2015/10/chronic-fatigue-patients-          authorities in the field of neuro-
   push-for-an-elusive-cure/409534/                                              science and people with chronic
                                                                                 fatigue syndrome.” Their work, he
“Goodbye Chronic Fatigue Syndrome, Hello SEID”                                   says, suggests that a “mid-range”
kk www.sciencemag.org/news/2015/02/goodbye-chronic-fatigue-syndrome-             of exercise is best, with no exercise
   hello-seid                                                                    or too much exercise both making
                                                                                 the patient’s condition worse.
“A New Name, and Wider Recognition, for Chronic Fatigue Syndrome”
                                                                                 Their research, Louw says, “is very
kk www.newyorker.com/tech/elements/chronic-fatigue-syndrome-iom-report
                                                                                 therapy-specific. I encourage PTs to
                                                                                 look up their papers.”
REPORTS AND REVIEWS
“Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome:                      Davenport, however, argues that a
Redefining an Illness”                                                           “pain science approach” sometimes
kk www.nap.edu/read/19012/chapter/1                                              can underplay the value of patients
                                                                                 “listening to their body” in favor of
“Exercise As Treatment for Patients with Chronic Fatigue Syndrome”               the message that “pain perception
kk www.cochrane.org/CD003200/DEPRESSN_exercise-treatment-patients-               does not equal tissue damage.” It’s
   chronic-fatigue-syndrome                                                      an area in which, he says, “pain
                                                                                 science proponents and I have
SELECTED RESEARCH                                                                some robust debate.”
Davenport TE, Stevens SR, Van Ness JM, et al. Conceptual model for
 physical therapist management of chronic fatigue syndrome/myalgic               He adds that while “some interest-
 encephalomyelitis. Phys Ther. 2010;90(4):602-614.                               ing papers have come out in recent
                                                                                 years that seem to support the
Hornig M, Montoya JG, Klimas NG, et al. Distinct plasma immune signatures        etiology of possible aerobic-system
 in ME/CFS are present early in the course of the disease. Sci Adv. 2015;1(1).   dysfunction” in people with CFS,
                                                                                 a “causal link” to why CFS hap-
Nagy-Szakal D, Williams BL, Mishra N, et al. Fecal metagenomic profiles
                                                                                 pens—and thus how it might best be
 in subgroups pf patients with myalgic encephalomyelitis/chronic fatigue
                                                                                 addressed—remains elusive.
 syndrome. Microbiome. 2017;5:44.
                                                                                 Nicole Rabanal, meanwhile, follows
Snell CR, Stevens SR, Davenport TE, Van Ness JM. Discriminative validity of
                                                                                 developments in CFS research with
  metabolic and workload measurements for identifying people with chronic
                                                                                 all the intensity that her disease
  fatigue syndrome. Phys Ther. 2013;93(11):1484-1492.
                                                                                 will allow. She is encouraged by
Stevens SR, Davenport TE. Functional outcomes of anaerobic rehabilitation in     what she sees.
  a patient with chronic fatigue syndrome: case report with 1-year follow-up.
                                                                                  “Tremendous research is being
  Bulletin of the IACFS/ME. 2010;18(3):93-98.
                                                                                 conducted around the world,” she
Van Cauwenbergh D, De Koonung M, Ickmans K, Nijs J. How to exercise              says. “In Norway they’re looking
  people with chronic fatigue syndrome: evidence-based practice guidelines.      at rituximab”—a medication used
  Eur J Clin Invest. 2012.42(10):1136-1144.
24                                          PTinMOTIONmag.org / September 2017
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