An international clinical trial led by researchers at the Harvard School of Public Health (HSPH) has found that AIDS-fighting antiretroviral drug combinations given to pregnant and breastfeeding women in Botswana, Africa, prevented 99% of the mothers from transmitting the human immunodeficiency virus (HIV) to their infants.

“This is the lowest rate of mother-to-child transmission recorded in a study from Africa, or among breastfeeding infants,” said lead author Roger Shapiro, Associate Professor of Medicine at Harvard Medical School and Harvard School of Public Health. The mother-to-child transmission rate in the study was 1.1% when the infants were breastfed to age 6 months. “Previous interventions using shorter or less comprehensive drug treatment regimens have been unable to get rates below 5%, and without any intervention, the infection rate would be at least 25% by 6 months,” said Shapiro.

The study was also the first randomized clinical trial to compare highly active antiretroviral therapy (HAART) regimens used during pregnancy or breastfeeding.

The article will appear in the June 17 edition of The New England Journal of Medicine. It is accompanied by an editorial by Dr. Lynne Mofenson of the National Institutes of Heath, who notes the important role for maternal HAART use during pregnancy and breastfeeding, particularly among women who also qualify for HAART as treatment for their own health. Dr. Mofenson states, “The intervention that would have the most substantial impact on HIV-1-related maternal deaths and perinatal infections throughout the world is the initiation of lifelong antiretroviral therapy in pregnant and lactating women infected with HIV-1 who meet the treatment criteria.”

Breastfeeding is normally the best way to feed an infant and is one of the most critical factors for improving child survival in developing nations. A woman infected with HIV, however, can transmit the virus to her child during breastfeeding, as well as during pregnancy, labor and delivery.

The research was part of the Mma Bana Study (meaning “mother of the baby” in Setswana) conducted in southern Botswana as a collaboration between HSPH and the Botswana government (the Botswana-Harvard AIDS Institute Partnership) to improve health for women and children. Established in 1996, the partnership is a collaborative research and training initiative between the Government of Botswana and the Harvard School of Public Health AIDS Initiative.

The use of HAART to prevent mother-to-child HIV transmission is one of the most successful public health interventions to prevent the transmission of AIDS in pregnancy. Little has been known, however, about its promise for halting HIV transmission from mother to infant through breastfeeding in areas of the world where formula feeding is neither safe nor feasible, including most of sub-Saharan Africa.

The study compared the suppression of the mother’s HIV virus at delivery and throughout breastfeeding among women assigned to receive one of three treatment regimens. Overall, 730 HIV-infected pregnant women were included in the study and most started HAART early in the third trimester of pregnancy. Almost all women achieved viral suppression by delivery, and their virus remained undetectable throughout breastfeeding. All three HAART regimens consisted of commonly used antiretroviral combinations with three active drugs. Similar results were found for all treatment groups, including 560 women who were randomized to receive either zidovudine, lamivudine, and abacavir (co-formulated as Trizivir) or zidovudine, lamivudine, lopinivir/ritonavir (Kaletra/Combivir), and 170 sicker women who qualified for treatment for their own health and received zidovudine, lamivudine, and nevirapine (Nevirapine/Combivir) provided by the Botswana government.

All HAART regimens used in the study were found to be highly effective at suppressing the HIV virus, said the authors. They also found the HAART regimens used in the study were safe and generally well-tolerated.

“Until now, HIV-infected mothers in Africa were faced with a choice between breastfeeding and a high risk of infecting their children with HIV, or using formula and risking high infant morbidity and mortality from other diseases associated with not breastfeeding. This study provides a more satisfactory solution,” said senior author Max Essex, Mary Woodard Lasker Professor of Health Sciences and chair of the Harvard School of Public Health AIDS Initiative.

The rates of infection with HIV in southern Africa are 3 to 5 times higher than in the rest of sub-Saharan Africa and more than 100 times higher than in the rest of the world. This discrepancy is much greater for women and children. While about 90% of the AIDS patients in the U.S. or Europe receive effective treatment, a much smaller percentage of patients in Africa receive adequate treatment. Children who are HIV infected are much less likely to be in treatment programs, and are usually destined to die of HIV/AIDS at a young age. This makes it even more critical that effective measures are available to prevent them from becoming infected.

The Mma Bana Study findings already have influenced WHO guidelines on the use of HAART to prevent mother-to-child HIV transmission. For the first time, WHO recently recommended that all HIV-infected mothers or their infants take antiretroviral drugs while breastfeeding to prevent HIV transmission. The Botswana government is preparing to roll out a program to provide HAART to all pregnant women with HIV, said Shapiro. Other countries are considering doing the same.

The research was supported by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health. The Fogarty International Center supported several trainees involved in this study. Other Boston institutions participating in the study included Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Children’s Hospital Boston, and Massachusetts General Hospital.

“Antiretroviral Regimens in Pregnancy and Breast-Feeding in Botswana,” Roger Shapiro, Michael Hughes, Anthony Ogwu, Doug Kitch, Shahin Lockman, Claire Moffat, Joseph Makhema, Sikhulile Moyo, Ibou Thior, Kenneth McIntosh, Erik van Widenfelt, Jean Leidner, Kathleen Powis, Aida Asmelash, Esther Tumbare, Sheryl Zwerski, Usha Sharma, Edward Handelsman, Kinuthia Mburu, Oluwemimo Jayeoba, Evans Moko, Sajini Souda, Edmund Lubega, Maida Akhtar, Carolyn Wester, Wendy Snowden, Marisol Martinez-Tristani, Loeto Mazhani, Max Essex, NEJM, Vol. 362, No. 24, June 17, 2010.

Visit the HSPH website for the latest news, press releases and multimedia offerings.

Source:
Todd Datz
Harvard School of Public Health

View drug information on Trizivir.

Although the Americans with Disabilities Act (ADA) has helped increase awareness of barriers faced by people with disabilities, and advances in science and engineering have led to better assistive technologies that make it easier for individuals to lead productive, independent lives, outdated regulations too often impede access to health care coverage and assistive devices for many who need them, says a new report by the Institute of Medicine.

The report calls on Congress and appropriate federal agencies to improve decision making about what and who Medicare and Medicaid will cover and to eliminate waiting periods for qualified individuals to receive Medicare coverage. The federal government should find ways to ease restrictions that prevent people from getting effective assistive services and technologies to help them live as independently as possible and participate in work and other activities outside the home.

“The number of Americans who have disabilities will grow significantly in the next 30 years as the baby boom generation enters late life. If one considers people who now are disabled, those likely to develop a future disability, and people who are or will be affected by the disabilities of family members or others close to them, it becomes clear that disability will eventually affect the lives of most Americans,” said Alan M. Jette, director, Health and Disability Research Institute, Boston University School of Public Health, Boston, and chair of the committee that wrote the report. “Increasingly, scientific evidence reveals that disability results, in large part, from actions society and individuals take. The sobering reality, however, is that over the past two decades, far too little progress has been made in adopting major public policy and practice advances to reduce disability in America.”

Currently, more than 40 million Americans – at least one in seven – have physical mobility, sensory, or other impairments or limitations. Since IOM’s previous reports in 1991 and 1997 that highlighted disability as a pressing public health issue, there has been growing recognition that disability is not inherent in individuals, but rather is the result of interactions between people and their physical and social environments. Many aspects of the environment contribute to limitations associated with disability — for example, inaccessible transportation systems and workplaces, restrictive health insurance policies, and telecommunications and computer technologies that do not consider people with vision, hearing, or other disabilities.

The ADA — and other policies aimed at reducing barriers for people with disabilities — has helped to increase recognition of environmental obstacles, but its implementation and enforcement have often been disappointing, the committee said. Ironically, even within health care facilities, people with disabilities encounter equipment and surroundings that are not designed to accommodate their needs — for example, examination tables and weight scales that are difficult for people in wheelchairs to use. Information materials for people with vision or hearing loss are frequently limited, as well.

The committee said it was encouraging to find that in older adults, the chances of having certain kinds of activity-limiting disabilities have declined during the last two decades. However, data for younger and middle-aged adults suggest an increasing risk for disability and for conditions that contribute to disability – notably, physical inactivity, diabetes, and obesity. These trends raise concerns that the next generation of people entering late life may experience more disability than the current population of seniors.

Steps needed to ensure that the growing population of American with disabilities is able to lead full lives and avoid lost productivity include the modification of Medicare’s “in home use” requirement for durable medical equipment, for example, a wheelchair or scooter. Current regulations stipulate that equipment must be “appropriate for use in the home,” which has been interpreted to mean a device should not be covered if it would be used only outside the home, such as an item for use in an office. Policies may also keep people from obtaining equipment that is safe and durable to use for getting around outside as well as inside the home. Other needed steps are the evaluation of new approaches for supplying assistive equipment, like renting or recycling used equipment, and rethinking narrow and outdated “medical necessity” rules that do not reflect the current emphasis on promoting independence and community integration for people with disabilities.

In addition, government at all levels should support continued research to evaluate and improve the methods used for determining fair payments for health services. These methods should not provide incentives for health plans to avoid people with disabilities, and they should encourage the coverage of care needed to manage chronic health conditions. Overall, policymakers should increase support for research on disability, which is seriously underfunded, considering the impact of disability on individuals, families, and communities.

To improve health care coverage for working-age people with disabling health conditions, Congress should eliminate the two-year waiting period for Medicare eligibility for those who are receiving Social Security Disability Insurance (SSDI). This waiting period is a serious hardship for individuals who have already qualified for disability insurance because they have a serious medical condition that precludes working. Officials also should test modifications in SSDI and other policies that would encourage people who are able to return to work to do so without losing their Medicare or Medicaid coverage, the report says. Regarding access to Medicaid for children with disabilities, Congress should extend Medicaid and other public health program coverage from age 18 through 21, to help young people with disabilities successfully transition from pediatric to adult health care and independent living.

The U.S. Department of Justice should continue to vigorously pursue and publicize settlements and litigation of violations in health care institutions and should issue guidelines for health care professionals and institutions that describe expectations for compliance with the ADA. Compliance with federal accessibility standards and guidelines should be an explicit factor in the accreditation of hospitals and clinics.

###

The study was sponsored by the Centers for Disease Control and Prevention, National Institute on Disability and Rehabilitation Research, and National Center for Medical Rehabilitation Research. Established in 1970 under the charter of the National Academy of Sciences, the Institute of Medicine provides independent, objective, evidence-based advice to policymakers, health professionals, the private sector, and the public. The National Academy of Sciences, National Academy of Engineering, Institute of Medicine, and National Research Council make up the National Academies. A committee roster follows.

INSTITUTE OF MEDICINE

Board on Health Sciences Policy

Committee on Disability in America

Alan M. Jette, Ph.D., P.T., M.P.H. (chair)
Director
Health and Disability Research Institute, and
Professor of Health Policy and Management
Boston University School of Public Health
Boston

Elena M. Andresen, Ph.D.
Professor and Chief
Epidemiology Division
Department of Health Services Research, Management, and Policy
University of Florida Health Sciences Center
Gainesville

Michael Chernew, Ph.D.
Professor
Department of Health Care Policy
Harvard Medical School
Boston

Dudley S. Childress, Ph.D.
Professor of Biomedical Engineering and Physical Medicine and Rehabilitation
McCormick School of Engineering and Feinberg School of Medicine
Northwestern University
Chicago

Vicki A. Freedman, Ph.D.
Professor
Department of Health Systems and Policy
School of Public Health
University of Medicine and Dentistry of New Jersey
Newark

Patricia Hicks, M.D.
Associate Director of Pediatrics, and
Director
Continuity of Care Clinic
University of Texas Southwestern Medical Center
Dallas

Lisa I. Iezzoni, M.D., M.Sc.
Professor of Medicine
Harvard Medical School, and
Associate Director
Institute for Health Policy
Massachusetts General Hospital
Boston

June Isaacson Kailes, M.S.W., L.C.S.W.
Associate Director
Center for Disability Issues and the Health Professions
Western University of Health Sciences
Playa del Rey, Calif.

Laura Mosqueda, M.D.
Director of Geriatrics and Professor of Family Medicine
Irvine School of Medicine
University of California
Irvine

P. Hunter Peckham, Ph.D.
Donnell Professor of Biomedical Engineering and Orthopaedics
Case Western Reserve University
Cleveland

James Marc Perrin, M.D.
Professor of Pediatrics
Harvard Medical School and Massachusetts General Hospital
Boston

Margaret A. Turk, M.D.
Professor of Physical Medicine and Rehabilitation
Upstate Medical University
State University of New York
Syracuse

Gregg Vanderheiden, Ph.D.
Professor of Industrial and Biomedical Engineering
University of Wisconsin
Madison

John Whyte, M.D., Ph.D.
Director
Moss Rehabilitation Research Institute
Philadelphia

INSTITUTE STAFF

Marilyn J. Field, Ph.D.
Study Director

Contact: Maureen O’Leary

The National Academies

According to a new study from researchers at Duke University, total knee arthroplasty (TKA) procedures performed in older patients with osteoarthritis of the knee result in long-term, significant improvement of physical functioning and motor skills when compared to patients who do not receive TKA.

Published in the July 2009 issue of Medical Care, the study examined physical functioning and gauged outcomes in a national sample of Americans aged 65 and older for up to four years-a longer period than previous TKA studies. Relative to the untreated comparison group, recipients of total knee replacements experienced significant improvement in function, including a 17.5% increase in mobility, a 39.3% improvement in motor skills; and a 46.9% decrease in limitations in activities of daily living such as bathing and dressing oneself.

The number of total knee replacements performed in the United States has increased dramatically since 1990; currently 581,000 such procedures are performed every year. This number is expected to increase markedly as Baby Boomers age.

“In this era of cost-cutting, policymakers have underscored the importance of evaluating treatments in terms of effectiveness and benefits to patients,” says lead author Frank Sloan, Ph.D., McMahon professor of health policy and management and professor of economics at Duke University. “Our findings show that knee replacements are effective in treating patients with advanced osteoarthritis, contributing to reduced disability and improved quality of life for these individuals. Such findings are extremely important for the broader context of discussions about healthcare reform, cost-containment, device quality, and patient safety.”

For the study, Duke researchers identified 2272 patients diagnosed with osteoarthritis of the lower leg using data from the Health and Retirement Study (HRS) linked to Medicare claims from 1994 through 2006. Of that group, 516 underwent TKA procedures and 1756 did not. Researchers used propensity score matching to generate 515 pairs of treated and untreated individuals who were matched on relevant, measurable factors such as baseline functional status, other health conditions, socioeconomic characteristics, and time before TKA or diagnosis.

Among the patients who underwent TKA, baseline physical functioning measures were taken at an interview before and closest to surgery. For the comparison group, these measures were taken from an interview preceding and closest in time to the year of their first diagnosis with osteoarthritis of the lower leg. Each pair was followed for up to four years, and their resulting physical abilities were compared.

The study’s mobility, gross motor skills, large muscle activities, and limitations in activities of daily living indices accounted for a wide breadth of physical activities, including getting in and out of bed; the ability to bathe and dress oneself; sitting for two hours; getting up from a chair; stooping, kneeling, and crouching; walking across the room, one block, and several blocks; climbing one flight and several flights of stairs; and pushing and pulling a large object.

The study comes at a time when Congress and the nation’s healthcare agencies are looking for ways to identify diagnostics and therapies that offer the greatest value to patients and the healthcare system. Representatives Bill Pascrell Jr. (D-NJ) and Lloyd Doggett (D-TX) have introduced legislation to establish a federally-funded registry of patients who have received artificial hips or knees, providing researchers and policymakers with an ongoing source of data about patient outcomes with such devices and related surgical procedures.

According to Sloan, total knee replacement has repeatedly been shown to offer clinical benefits for patients with osteoarthritis, a major risk factor for disability in the United States. Recently, a team at Brigham and Women’s Hospital and the Boston University School of Public Health confirmed that, for older adults with advanced osteoarthritis, total knee replacement also appears to be a cost-effective procedure across all patient risk groups.

“We know that the inability to perform activities of daily living is highly predictive of nursing home admittance, as patients can no longer care for themselves,” says Sloan. “TKA offers the potential for extending independence and therefore delays the need for assisted living.”

The Duke University research was supported by a grant from the Institute for Health Technology Studies (InHealth). The coauthors of this study are David Ruiz Jr., MA, and Alyssa Platt, MA.

Source:
Robyn Stein
InHealth: The Institute for Health Technology Studies

A coalition of 34 consumer groups, led by the Medicare Rights Center, has begun to lobby Congress to revise a law that requires individuals with disabilities to wait two years to become eligible for Medicare after they begin to receive Social Security disability benefits, the Dallas Morning News reports. Medicare implemented the waiting period in 1972, when Congress expanded the program to cover individuals with disabilities, to limit the cost and ensure only those with severe and long-term disabilities would qualify for the program.

However, according to a report released earlier this month, the law is “sentencing people to inadequate health care, poverty and death.” The center estimates that elimination of the waiting period would cost $8.7 billion annually, although savings of $4.3 billion in Medicaid would offset some of the cost.

Deane Beebe, a co-author of the report, said, “It’s unconscionable to leave people stranded without affordable health care coverage at the exact moment they need it most.” She recommended that Congress finance the elimination of the waiting period through reduced reimbursements to private Medicare Advantage plans.

Some Concerns
Robert Moffitt, an analyst at the Heritage Foundation, said, “Medicare is a financial wreck, with $33 trillion in unfunded liabilities,” adding “This would be another nail in the coffin.” Joseph Antos, a health care expert at the American Enterprise Institute, said, “Instead of opening the door to everyone, let’s do better at calculating financial need.” He added, “Some people do have other sources of insurance, so we should be careful about expanding a program that’s already facing serious financial problems itself” (Moos, Dallas Morning News, 4/26).

“Reprinted with permission from kaisernetwork. You can view the entire Kaiser Daily Health Policy Report, search the archives, or sign up for email delivery at kaisernetwork/dailyreports/healthpolicy. The Kaiser Daily Health Policy Report is published for kaisernetwork, a free service of The Henry J. Kaiser Family Foundation . © 2005 Advisory Board Company and Kaiser Family Foundation. All rights reserved.

Researchers at Arizona State University’s Polytechnic campus and the Military Amputee Research Program at Walter Reed Army Medical Center are teaming up to create the next generation of powered prosthetic devices based on lightweight energy storing springs.

The device, nicknamed SPARKy, short for Spring Ankle with Regenerative Kinetics, will be the first-of-its-kind smart, active and energy-storing transtibial or below-the-knee prosthesis.

Existing technology in prosthetic devices is largely passive and requires the amputee to use 20 to 30 percent more energy to propel themselves forward when walking compared to an able-bodied person, according to Thomas Sugar, ASU assistant professor of engineering at the Polytechnic campus.

Once complete, SPARKy is expected to provide functionality with enhanced ankle motion and push-off power comparable to the gait of an able-bodied individual.

“A gait cycle describes the natural motion of walking starting with the heel strike of one foot and ending with the heel strike of the same foot,” says Sugar. “The cycle can be split into two phases – stance and swing. We are concerned with storing energy and releasing energy (regenerative kinetics) in the stance phase.”

When you look at the mechanics of walking, it can be described as catching a series of falls, explains Sugar. In the team’s device, a tuned spring brakes falls and stores energy as the leg rolls over the ankle during the stance phase, similar to the Achilles tendon.

Sugar’s team, made up of doctoral students Joseph Hitt and Matthew Holgate, and Barrett Honors College student Ryan Bellman, have coined SPARKy a robotic tendon because of its bionic properties.
“What we hope to create is a robotic tendon that actively stretches springs when the ankle rolls over the foot, thus allowing the springs to thrust or propel the artificial foot forward for the next step,” says Sugar

“Because energy is stored, a lightweight motor can be used to adjust the position of a uniquely tuned spring that provides most of the power required for gait. Thus less energy is required from the individual.”

The team is the first to apply regenerative kinetics to design a lightweight prosthetic device. Others are using large motors combined with harmonic drives, a monopropellant or extremely high pressure oil.

Sugar’s team already has proof that SPARKy is working. In recent experiments with able-bodied subjects outfitted with a robotic ankle orthosis, or a powered assist device, the researchers found that the spring and motor combination was able to amplify the motor power by three-fold. This significant finding allows SPARKy to be downsized from a 6-7 kg motor system to a 1 kg (2 lb) system which is significant weight savings for those who wear a prosthetic.

“We expect this device to revolutionize prosthetics and will be especially helpful for military personnel wounded in active duty,” says Hitt.

The project is a multi-phased effort led by ASU’s Human Machine Integration Lab, Arise Prosthetics and Robotics Group, Inc. Arise Prosthetics is helping in the fitting of the device and Robotics Group, Inc. is designing embedded processors and motor amplifiers.

The first phase of SPARKy featuring the robotic tendon is expected to be ready for demonstration in December 2007. “I will know it is successful when a wounded solider is able to walk using the device on a treadmill,” says Sugar about this phase.

The project will culminate with the functionality to support walking in a daily environment, which is expected in 2009.

About Dr. Thomas Sugar

Dr. Thomas Sugar has built a large research program in medical robotics, as a co-investigator on a National Institutes of Health (NIH) contract for stroke rehabilitation, the principal investigator on an NIH grant on robotic spring ankles for gait assistance, and principal investigator on the three-year Department of Defense grant to build SPARKy.

ASU’s Polytechnic campus, located in southeast Mesa, offers bachelor and graduate degree programs, unparalleled by other Arizona state universities, through the Morrison School of Management and Agribusiness, East College, the College of Science and Technology, and the School of Educational Innovation and Teacher Preparation.

poly.asu.edu.

Scientists working at the Carnegie Institution’s Department of Embryology, with colleagues, have overturned previous research that identified critical genes for making muscle stem cells. It turns out that the genes that make muscle stem cells in the embryo are surprisingly not needed in adult muscle stem cells to regenerate muscles after injury. The finding challenges the current course of research into muscular dystrophy, muscle injury, and regenerative medicine, which uses stem cells for healing tissues, and it favours using age-matched stem cells for therapy. The study is published in the June 25 advance on-line edition of Nature.

Previous studies have shown that two genes Pax3 and Pax7, are essential for making the embryonic and neonatal muscle stem cells in the mouse. Lead researcher Christoph Lepper, a predoctoral fellow in Carnegie’s Chen-Ming Fan’s lab and a Johns Hopkins student, for the first time looked at these two genes in promoting stem cells at varying stages of muscle growth in live mice after birth.

As Christoph explained: “The paired-box genes, Pax3 and Pax7 are involved in the development of the skeletal muscles. It is well established that both genes are needed to produce muscle stem cells in the embryo. A previous student, Alice Chen, studied how these genes are turned on in embryonic muscle stem cells (also published in Nature). I thought that if they are so important in the embryo, they must be important for adult muscle stem cells. Using genetic tricks, I was able to suppress both genes in the adult muscle stem cells. I was totally surprised to find that the muscle stem cells are normal without them.”

The researchers then looked at whether the same was true upon injury, after which the repair process requires muscle stem cells to make new muscles. For this, they injured the leg muscles between the knee and ankle. They were again surprised that these muscle stem cells, without the two key embryonic muscle stem cell genes, could generate muscles as well as normal muscle stem cells. They even performed a second round of injury and found that the stem cells were still active.

The scientists then wondered when these genes become unnecessary for muscle stem cells to regenerate muscles. It turned out that these embryonic genes are important to muscle stem cell creation up to the first three weeks after birth. What makes the muscle stem cells different after three weeks? The scientist believe that these two embryonic muscle stem cell genes also tell the stem cells to become quiet as the organism matures. After that time is reached, they “hand over” their jobs to a different set of genes. The researchers suggest that since the adult muscle stem cells are only activated when injury occurs (by trauma or exercise), they use a new set of genes from those used during embryonic development, which proceeds without injury. The scientists are eager to find these adult muscle stem cell genes.

“We are just beginning to learn the basics of stem cell biology, and there are many surprises,” remarked Allan Spradling, director of Carnegie’s Department of Embryology. “This work illustrates the importance of carrying out basic research using animal models before rushing into the clinic with half-baked therapies.”

The research was funded by the Carnegie Institution, NIH, and the Riley Children’s Foundation.

Listen to the scientist in his own words here.

Source:
Christoph Lepper
Carnegie Institution

The American Physical Therapy Association (APTA) House of Delegates elected officers, directors, and a member of the Nominating Committee during its annual meeting prior to PT 2009, June 10-13, in Baltimore.

R. Scott Ward, PT, PhD, was reelected president. Paul A. Rockar Jr, PT, DPT, MS, was elected vice president. Mary C. Sinnott PT, DPT, MEd, Nicole L. Stout, PT, MPT, CLT-LANA, and Kathleen K. Mairella, PT, DPT, MA, were elected directors. Aimee B. Klein, PT, DPT, DSc, OCS, was reelected a director. James E. Hughes, PT, was elected to the Nominating Committee. All will serve three-year terms except for Mairella who will serve the remaining two years of Rockar’s term as director.

“These outstanding leaders bring a wealth of experience to the profession and the association,” said APTA Chief Executive Officer John D. Barnes. “I am looking forward to working alongside each of them to help the profession reach its goal of Vision 2020.”

Ward has served as APTA president since 2006. He is chair of the Department of Physical Therapy at the University of Utah in Salt Lake City, and is immediate past-chair of the Rehabilitation Committee of the American Burn Association. He is also a member of the Burn Rehabilitation and Research Consensus Summit Group and served as a member of APTA’s Guide to Physical Therapist Practice Volume 3 Practice Panel, among many other professional activities.

Rockar is CEO of the Centers for Rehab Services at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. He is also adjunct assistant professor at Duquesne University Rangos School of Health Sciences and at the University of Pittsburgh School of Health and Rehabilitation Sciences in Pittsburgh. In addition, Rockar is a partner at Mountain State Physical Therapy in Fairmont, West Virginia. He has served on the APTA Federal Government Affairs Committee and as APTA representative to the AMA CPT Coding Health Care Professional Advisory Committee, among other activities.

Sinnott is clinical associate professor in the Doctor of Physical Therapy Program and director of the entry-level Doctor of Physical Therapy Program at Temple University in Philadelphia. She also maintains a clinical acute care practice at Temple University Hospital. Among many other activities, she is the former president of APTA’s Acute Care and Health Policy and Administration sections. A past recipient of the Signe BrunstrГ¶m Award for Excellence in Clinical Teaching, she also has been honored by the Acute Care Section with an award for clinical excellence established in her name.

Stout practices at the Breast Care Center at the National Naval Medical Center in Bethesda, Maryland, and is the immediate past president of the APTA Oncology Section, among other leadership positions.

Mairella is assistant professor and assistant director of clinical education in the Doctoral Program in Physical Therapy in the School of Health Related Professions at the University of Medicine and Dentistry of New Jersey in Newark, New Jersey. Among other activities,
Mairella served as president of the American Physical Therapy Association of New Jersey and is a member of the APTA Private Practice, Health Policy and Administration, Education, and Orthopaedic sections.

Klein is clinical assistant professor in the Graduate Programs in Physical Therapy and coordinator of the Clinical Residency Program in Orthopaedic Physical Therapy and Manual at the MGH Institute of Health Professions in Boston, Massachusetts. Among many activities, Klein is a former trustee of APTA’s Physical Therapy Political Action Committee.

Hughes practices in the Work Rehabilitation Center of the Physical Medicine and Rehabilitation Department of the Mayo Clinic in Rochester, Minnesota. Among other activities, he is a member of APTA’s Orthopaedic and Health Policy and Administration sections.

The APTA Board of Directors comprises 15 members-6 officers and 9 directors. Board members assume office at the close of the House of Delegates at which they were elected. A complete term for a board member is defined as 3 years.

The APTA Nominating Committee is comprised of 5 members. Members of the Nominating Committee assume office at the close of the House of Delegates at which they were elected. A complete term for a Nominating Committee member is defined as 3 years.

APTA’s Annual Conference & Exposition strives to empower, educate, and encourage physical therapists and physical therapist assistants. All educational sessions are designed to reflect evidence in practice and to integrate the best research evidence with clinical expertise and patient/client values. For information about PT 2009, visit apta/annualconference.

Physical therapists are highly-educated, licensed health care professionals who can help patients reduce pain and improve or restore mobility – in many cases without expensive surgery or the side effects of prescription medications. APTA represents more than 72,000 physical therapists, physical therapist assistants, and students of physical therapy nationwide. Its purpose is to improve the health and quality of life of individuals through the advancement of physical therapist practice, education, and research. In most states, patients can make an appointment directly with a physical therapist, without a physician referral. Learn more about conditions physical therapists can treat and find a physical therapist in your area at moveforwardpt.

Source
American Physical Therapy Association

Resistance training, some of it job-specific, was successful in getting 90 percent of workers with severe rotator cuff injuries back to work, the majority (75 percent) at their previous job, after traditional physical therapy had failed to do so. Furthermore, all but one of the 42 employees in the study (98 percent) reported satisfaction with the resistance-training program and its outcome.

Dr. Jamie Stark described this and five related studies of workers suffering work-related rotator cuff and lumbar fusion injuries at Experimental Biology 2007, meeting in Washington, DC. His presentations are part of the scientific program of The American Physiological Society.

Participants in the rotator cuff study represent a class of “worse-case-scenarios” of work-related injuries. Rotator cuff injuries involve those muscles and tendons that stabilize the shoulder and can be caused by pulling the arm out of place, by falls and other accidents. All 42 of the employees had been through surgery to repair their torn muscles or ligaments. All had already gone through weeks of traditional rehabilitation and physical therapy. Even so, none had been judged capable of going back to work and thus were eligible for disability and workmen’s compensation settlements.

This was just the patient population Dr. Stark, director of Research and Development at the Athletic and Therapeutic Institute in Chicago and his colleagues at the research division of the Institute wanted. Nothing had worked for these patients, and the researchers figured that what would work for them also would work for employees with less severe injuries.

The injured employees attended the Institute program four hours a day, five days a week, on average for six weeks. Their daily training began with warm up, stretching, and core exercises for balance and proper biomechanics, then moved to free weight resistance training of the upper and lower body. Unlike traditional physical therapy programs after injuries, this program was a modified version of what professional and collegiate athletes do using free weights. On the third day of the week, the exercises involved less weight than the previous two days but were much more dynamic, addressing specific injury and biomechanical patterns related to the workers’ previous jobs. A drywaller, for example, would work muscles used in lifting large sheets of drywall overhead and in place. During the last two days of each week, the amount of weight used durinig free weight lifting was heavier than that of the first two days of the week.

At the end of the six weeks training, the workers were tested on physical function (a four hour protocol based on U.S. Department of Labor classifications of different types of work, re specific amounts of weight lifted for specific percentages of time). Ninety-six percent of patients met or exceeded the physical function levels of their previous job, and 90 percent went back to work, most at their previous job. Almost all employees were satisfied with the program, and so were employers.

Dr. Stark says “We are at a new era in which we can develop standardized exercise prescriptions that produce desired, achievable functional goals.” He believes doing that will meet the goals of all key stakeholders. Patients want to regain full function as soon as possible and be satisfied with their physical and work outcomes. Employers want workers to come back to work as soon as possible, as fully as possible, at a cost that prevents escalation in insurance premiums.

And payors, whether insurance companies or self-insured employers, are interested in the cost benefit between getting a worker back to the job at a functioning level (costs of medical, physical therapy, and other rehabilitation programs such as those these workers went through) and a worker’s not being able to go back to work at all or at his or her previous level (costs of long-term disability settlement, workman’s compensation). “To date,” says Dr. Stark, “this model of rehabilitation using intense free weight training has proved objective, measurable, and successful in patient satisfaction, return to work, and cost benefit.”

The researchers now hope to test the model in a larger prospective trial of workers at varying levels of injury in order to demonstrate increased outcome efficacy with a standardized prescription and concurrently measure cost-benefit to the worker’s compensation system.

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Contact: Sylvia Wrobel

Federation of American Societies for Experimental Biology

Inpatient rehabilitation facilities (IRFs) are projected to receive approximately $6.3 billion in payments from the Medicare program in fiscal year (FY) 2008, under a proposed rule announced today by the Centers for Medicare & Medicaid Services (CMS). The proposed rule would update payment rates and modify payment policies for services furnished to Medicare beneficiaries for discharges occurring on or after October 1, 2007 through September 30, 2008. The rule’s provisions are estimated to increase Medicare payments to approximately 1,234 IRFs in FY 2008 by approximately $150 million.

“Today’s proposed rule is designed to ensure accurate payments for intensive rehabilitation care provided to Medicare beneficiaries in IRFs,” said Acting CMS Administrator Leslie V. Norwalk, Esq. “This continues Medicare’s commitment to support access to inpatient rehabilitation facility services while at the same time improving the appropriateness and consistency of payment for beneficiary care in all post acute settings.” These settings include IRFs, skilled nursing facilities, home health care, and long-term care hospitals.

The proposed rule would increase the IRF payment rate by 3.3 percent, based on the rehabilitation, psychiatric, and long-term care hospital (RPL) market basket. The RPL market basket is designed to capture inflation in the costs of goods and services required to provide the specialized services offered by these facilities, similar to the market basket that applies to general acute care hospitals.

The IRF Prospective Payment System (PPS) was first implemented for cost reporting periods beginning on or after January 1, 2002. The objective of implementing a PPS for IRFs was to increase the accuracy of the payments made to the facilities for the resources they use to furnish care to Medicare beneficiaries, in addition to enhancing the efficient delivery of quality care. IRFs have received an increase in payment rates each Federal fiscal year since the IRF PPS was implemented.

The proposed rule would continue the existing phase-in to a 75 percent compliance threshold (75 Percent Rule), a requirement that when fully phased in requires that at least 75 percent of an IRF’s total inpatient population have one of the 13 designated medical conditions for which intensive inpatient rehabilitation services are medically necessary. The 75 percent rule was initially adopted in 1983 to distinguish those hospitals and hospital units which would be eligible for exemption from the inpatient prospective payment system (IPPS) and would continue to be reimbursed on a cost basis. Since the institution of the IRF PPS, CMS no longer reimburses IRFs on a cost basis. However, in general the IRF PPS provides higher payment levels than would be paid for these cases under the IPPS, thus the need to continue this important classification initiative.

CMS uses the start of a provider’s cost reporting period to determine which compliance threshold to apply to determine if a hospital should be classified as an IRF. For example, in accordance with Section 5005 of the Deficit Reduction Act of 2005 (DRA), the 60 percent threshold applies for cost reporting periods beginning during the 12-month period beginning on July 1, 2006. The compliance threshold increases to 65 percent for cost reporting periods beginning during the 12-month period beginning on July 1, 2007. For cost reporting periods beginning on and after July 1, 2008, of the compliance percentage is 75 percent.

Under the 75 percent rule, CMS regulations allow comorbidities that meet the regulatory criteria to be used to determine the compliance percentage for cost reporting periods that begin before July 1, 2008. This provision, adopted for IRFs with cost reports beginning on or after July 1, 2004 as part of a four year transition for the new provisions of the 75 percent rule, is scheduled to expire for cost reporting periods that will begin on or after July 1, 2008. Given the transitional nature of the provision, the proposed rule does not extend its application, but CMS is soliciting comments and research to support current policy or options to extend this provision for a specified time or to make it a permanent part of the IRF PPS policy.

The proposed rule would increase the high-cost outlier threshold to $7,522 from $5,534 in FY 2007, based on an analysis of 2005 data which indicates that this threshold would maintain estimated outlier payments at 3 percent of total payments under the IRF PPS. Although the higher threshold would mean that fewer cases would qualify for outlier payments, a lower outlier threshold would require an across-the-board reduction in the base payment for an IRF stay in order to maintain budget neutrality. The high-cost outlier threshold may be updated for the final rule based on analysis of 2006 data. The proposed rule would also clarify that short-stay transfer cases that meet the criteria to qualify for outlier payments are eligible to receive the additional payments.

Finally, the proposed rule would modify the wage index methodology as it applies to IRFs in certain rural areas where no hospitals exist to generate wage index data. The proposed rule would provide for CMS to use an average wage index from all contiguous Core Based Statistical Areas as a reasonable proxy for the wage index in the rural area.

Comments on the proposed rule will be accepted until July 2, and a final rule will be issued later this year. Additional information about the IRF proposed rule is posted on the CMS web site at: www.cms.hhs/InpatientRehabFacPPS.

www.cms.hhs

Stammering and stuttering have the same meaning – it is a speech disorder in which the person repeats or prolongs words, syllables or phrases. The person with a stutter (or stammer) may also stop during speech and make no sound for certain syllables. People who stutter often find that stress and fatigue make it harder for them to talk flowingly, as well as situations in which they become self-conscious about speaking, such as public speaking or teaching. Most people who stutter find that their problem eases if they are relaxed.

According to Medilexicon’s medical dictionary, to stammer is “To hesitate in speech, halt, repeat, and mispronounce, by reason of embarrassment, agitation, unfamiliarity with the topic, or as yet unidentified physiologic causes. To mispronounce or transpose certain consonants in speech.”

We all have the capacity to stutter if pushed far enough. This may happen during a very stressful interrogation in a police station, talking to emergency services on the telephone, or trying to respond to a particularly agile and aggressive lawyer while on the witness stand in court.

Famous people who stammered

Stammering does not reflect a person’s intelligence or personality. Here is a list of famous people who stammer/stammered:

Aesop – Greek storyteller
Alan Turing – Computer science founder
Aneurin Bevan – Labour Party MP and Minister
Anthony Quinn – Actor (Zorba the Greek)
Aristotle – Philosopher
Arnold Bennett – British writer/journalist
Bruce Oldfield – British fashion designer
Carly Simon – Singer (You’re so vain)
Charles Darwin – Scientist/Naturalist
Claudius Cesar – Roman Emperor.
Demosthenes – Greek orator
Sir Jonathan Miller – British theatre/opera director
Elizabeth Bowen – Author
Erasmus Darwin – Scientist/Doctor, grandfather of Charles Darwin
Field Marshall Lord Carver – British military leader/author
Gareth Gates – English pop star
George Washington – American President
Harvey Keitel – Actor (Life on Mars)
Isaac Newton – Scientist
Jack Harold Paar – US comedian & TV host
James Stewart – Actor (It’s a wonderful life)
John Montague – Poet/Author
Joseph Priestley – Scientist (discovered oxygen)
Kenneth Tynan – British theatre critic, writer
Kim Philby – British double agent for the Soviets
King Charles I – England 1625-1649
King George VI – UK 1937-1952
Lenin – Russian revolutionary
Lewis Carroll – Author (Alice in Wonderland)
Louis II the Stammerer, King of France, 877-879
Marion Davies – Famous silent-movie actress
Michael Bentine – British comedian, script-writer and TV star
Michael Ramsey – Archbishop of Canterbury 1961-1974
Miguel de Cervantes Saavedra – Author
Nevil Shute (1900-1960) – Author
Philip Larkin – Poet, author, critic
Raymond Massey – Actor (High treason)
Richard Condon – Author
Robert Boyle (1627-1691) – Scientist
Robert Heinlein – Author
Rowan Atkinson – Actor (Mr. Bean)
Sam Neill – Actor (Jurassic Park)
Samuel L. Jackson – (Pulp Fiction)
Somerset Maugham – Author
Theodore Roosevelt – American President
Thomas Becket – Archbishop of Canterbury 1162-1170
Thomas Jefferson – American President
Walter H. Annenberg – Publisher, diplomat, philanthropist
John Updike – Author
Bill Withers – Singer, songwriter (Ain’t no sunshine)

Stuttering is common when children are learning to speak. However, the majority of kids grow out of this stage of initial stuttering. For some, however, the problem persists and requires some kind of professional help, such as speech therapy. It is important that parents do not add to a child’s stress by drawing too much attention to the problem when they are trying to communicate verbally. The calmer a child feels the less acute the symptoms tend to become.
What are the signs and symptoms of stuttering?

Problems starting a word, phrase or sentence
Hesitation before certain sounds have to be uttered
Repeating a sound, word or syllable
Certain speech sounds may be prolonged
Speech may come out in spurts
Words with certain sounds are substituted for others (circumlocution)
Rapid blinking (when trying to talk)
Trembling lips (when trying to talk)
Foot may tap (when trying to talk)
Trembling jaw (when trying to talk)
Face and/or upper body tighten up (when trying to talk)
Some may appear out of breath when talking
Interjection, such as “uhm” used more frequently before attempting to utter certain sounds

What causes stuttering?
Experts are not completely sure. We do know that somebody with a stutter is much more likely to have a close family member who also has one, compared to other people. The following factors may also trigger/cause stuttering:

Developmental stuttering – as children learn to speak they often stutter, especially early on when their speech and language skills are not developed enough to race along at the same speed as what they want to say. The majority of children experience fewer and fewer symptoms as this developmental stage progresses until they can speak flowingly.
b>Neurogenic stuttering – when the signals between the brain and speech nerves and muscles are not working properly. This may affect children, but may also affect adults after a stroke or some brain injury. In rare cases neurogenic stuttering results in lesions (abnormal tissue) in the motor speech area of the brain.
Psychological factors – it used to be believed that the main reasons for long-term stuttering were psychological. Fortunately, this is not the case anymore. Psychological factors may make stuttering worse for people who stutter, such as stress, embarrassment, etc., but they are not generally seen as underlying long-term factors. In other words, anxiety, low self-esteem, nervousness, and stress therefore do not cause stuttering per se. Rather, they are the result of living with a stigmatized speech problem which can sometimes make symptoms worse.

What are the risk factors?

Family history – approximately half of all children who have a stutter that persists beyond the developmental stage of language have a close family member who stutters. If a young child has a stutter and also a close family member who stutters, his/her chances of that stutter continuing are much greater.
Age when stutter starts – a child who starts stuttering before 3.5 years of age is less likely to be stuttering later on in life. The earlier the stuttering starts the less likely it is to continue long-term.
Time since stuttering started – about three-quarters of all young children who stutter will stop doing so with one or two years without speech therapy. The longer the stuttering continues the more likely it is that the problem will become long-term without professional help (and even with professional help).
Sex of the person – long-term stuttering is four times more common among boys than girls. Experts believe there may be neurological reasons for this, while others blame the way family members react to little boys’ stuttering compared to little girls’ stuttering. However, nobody is really sure what the reason is.

When to seek professional help
Experts say that parents should consider visiting their GP (general practitioner, primary care physician) when:

The child’s stuttering has persisted for over six months
When the stuttering occurs more frequently
When it is accompanied with tightness of the facial and upper body muscles
When it interferes with the child’s schoolwork
When it causes emotional difficulties, such as fear of places or situations
When it persists after the child is 5 years old

How is stuttering diagnosed?
Some aspects of stuttering are obvious to everyone, while others are not. To have a comprehensive and reliable diagnosis the patient should be examined by a well-qualified Speech-Language Pathologist (SLP).

The SLP will note how many speech disfluencies the person produces in various situations, as well as the types of disfluencies. How the person copes with disfluencies will also be assessed, how the person reacts to such factors as teasing, which can exacerbate their problems. The SLP may perform some other assessments, such as speech rate and language skills – this will depend on the patient’s age and history. The SLP will analyze all the data and determine whether there is a fluency disorder. If there is one, the SLP will determine to what extent the disorder affects the patient’s ability to function and take part in daily activities.

It is vital to try to predict whether a young child’s stutter will become long-term. This can be fairly accurately done with the help of a series of tests, observations and interviews. Predicting whether an older child or an adult is likely to have continued stuttering over the long-term is less important because most likely the problem has been around long enough for the person to seek help. Assessments for older children and adults are aimed at gauging the severity of the disorder, and what impact it has on the person’s ability to communicate and function appropriately in daily activities.
What is the treatment for stuttering?
A good evaluation (diagnosis) is vital as this determines what the best treatment might be.

Treatments for people who stutter tend to be aimed at teaching the person skills, strategies, and behaviors that help oral communication. This may include:

Fluency shaping therapy

Controlling monitoring speech rate – this may involve practicing smooth, fluent speech at very slow speed, using short sentences and phrases. The person is taught to stretch vowels and consonants, while trying to secure continuous airflow. With practice the person gradually utters smooth speech at higher speed, and with longer sentences and phrases. Patients have higher long-term success rates if the sessions with the SLP are followed up regularly – this helps prevent relapses.
Breathing control – as the patient practices prolonged speech he/she also learns how to regulate breathing. Added to this is operant conditioning (controlling breathing, as well as phonation, and articulation (lips, jaw and tongue).

Stuttering modification therapy

The aim here is to modify the stuttering so that it is easier and requires less of an effort, rather than eliminating it. This therapy works on the principle that if anxiety exacerbates stuttering, using easier stuttering with less avoidance and fear will alleviate the stuttering. Charles Van Riper developed Block Modification Therapy in 1973; it includes four stages:

Stage 1 (Identification) – the therapist and the patient identify the core behaviors, secondary behaviors, and feelings and attitudes that accompany the stuttering.
Stage 2 (Desensitization) – the patient freezes stuttering behavior in an attempt to reduce fear and anxiety – this involves confronting difficult sounds, words and situations (rather than avoiding them), and stuttering intentionally (voluntary stuttering).
Stage 3 (Modification) – the patient learns easy stuttering. He/she learns how to apply: a) ‘cancellations’ – stopping a dysfluency, pausing for a moment, and then repeating the word, b) ‘pull-outs’- pulling out of a dysfluency into fluent speech, c) and ‘preparatory sets’ – anticipating words that cause stuttering and using ‘easy stuttering’ on those words.
Stage 4 (Stabilization) – the patient prepares practice assignments, makes preparatory sets and pull-outs automatic, and changes the way he/she sees himself/herself from being a stutterer to being a person who speaks fluently most of the time, but stutters mildly occasionally.

Electronic fluency devices

Some patients have responded well to this type of treatment, while others have not. The patients hear their voice differently. Altered auditory feedback effect can be done by speaking in unison with another person (as groups of people do when they are praying or singing), and blocking out the stutterer’s voice while talking – this is called masking. Some ear-pieces can echo the speaker’s voice so that they feel they are talking in unison with someone else. Most stutterers can sing flowingly without stuttering – it seems that talking in unison with someone else often has the same effect as singing on a stutterer.

How to behave when you are talking with somebody who stutters
People who are not used to talking to somebody with a stutter may be unsure about how to respond. This can make the listener to look away whenever the stutterer stutters, or try to help out by completing his/her missing words or phrases – or simply to try to avoid people who stutter altogether.

It is important to remember that a person who stutters is interested in communicating just like everybody else, and would like to be treated just like any other person. Focus should be on the theme of the speaker, the information he/she is conveying, rather than how it is coming across.

A stutterer is only too aware of what his/her speech is like and that it can take longer to utter phrases. In fact, this awareness can sometimes make the stuttering worse. The stress of knowing that it takes longer to say something may make the stutterer try to speed up, which often makes things worse. It is important that the listener gives out a feeling (vibes) of patience, calm and peace. An impatient listener, or a listener who seems impatient, may make it harder for a stutterer to speak. Attempting to fill in the gaps (saying the missing words) is often an attempt to help out, but can come over to the stutterer as impatience.

Telling the stutterer to relax, or to take a deep breath, may have helpful intentions, but could stress the stutterer more (it may help some, though). Stuttering is not simple to overcome, and cannot usually be easily sorted out with a few deep breaths.

If you are really not sure how to behave, and you are talking to a person who stutters and nobody else is around, it may be helpful to ask them what would be the most best way to respond to his/her stuttering.

Put simply – focus on the content of the speaker’s message, not how it is being delivered. Emit a sensation (vibes) of matter-of-fact patience, calm and peace.