PT still has a long way to go with issues on Capitol Hill

Thursday afternoon, June 9, at the conference was highlighted by "Critical Issues in Congress for Physical Therapy," a session that updated attendees on the APTA's agenda in Washington, DC, for this session of Congress.

Dave Mason, vice-president of governmental affairs for APTA, and Justin Moore, PT, associate director of federal legislative affairs, presented along with Kate Hull and Samantha Poole, representatives of the Washington, DC, consulting group Fierce, Isakowitz and Blalock, currently working with the APTA.

Mason began with an overview of lobbying strategy and by summarizing the organization's objectives. "The main challenge we face is that policy makers fail to understand physical therapy," he said. "PT is still largely considered an ancillary service."

Mason conceded that the APTA faces some daunting challenges in order to accomplish Vision 2020. For that reason, he said, it is important to deal with these viewpoints, rather than writing off those people who hold these assumptions as ignorant and misinformed.

"It's our job to change each individual's perceptions of the profession," he stressed. "Resistance to change can present problems. Until every lawmaker in Washington, DC, acknowledges physical therapy as a doctoral profession, we will be slowed by these stereotypes."

Political Landscape

After Mason's introduction, Poole summarized Congress' agenda for 2005 by saying that this was shaping up to be a most unusual campaign. "This is a rare year, in that there is no true legislative centerpiece for Congress to consider," she said.

Between the judicial process in the Senate, the fallout from the Terri Schiavo case, and the situation in Iraq, health care simply is not a pressing issue right now, Poole said. Nevertheless, Poole said she felt it was important for PTs to keep abreast of the big picture, so as to optimize timing in terms of getting initiatives passed.

Hull followed by outlining the likelihood for Congress to act on certain aspects of the health care system. When the country is facing a large deficit, as is currently the case, Hull said, it becomes difficult to pass new health care initiatives, which almost always increase spending.

In financial terms, the largest issue currently facing physical therapy is the cap on therapy under Medicare. With the current moratorium on the cap set to expire on the first day of the year 2006, PTs are facing a very real crisis if the moratorium cannot be extended or a similar agreement made.

Making this even more challenging is the fact that following 2004's Medicare reform, President Bush is likely to veto anything that would re-open the Medicare system.

However, Hull closed by saying that the forthcoming budget reconciliation will likely include significant Medicaid reform to the tune of a $10 billion reduction in spending. In return, she continued, Medicare will likely be re-opened, providing the most likely vehicle to tack on additional time to the therapy cap moratorium.

PT-Specific Issues

With the moment of truth approaching with regard to the therapy cap, Moore went into greater depth on the issue following questions from the audience. Moore acknowledged that the top obstacle to a cap repeal would be finding a way to replace the $4.3 to $7.6 billion that would likely be lost if the cap moratorium is not implemented on the first of the year.

As it currently stands, there would be two separate therapy caps–one for occupational therapy, and another for the combined services of physical and speech therapy. Alternatives to the current system include:

• Increasing the spending limit under the cap (estimated to be $1,770 for the year, and adjusted for inflation going forward);

• A gradual "ramping" toward repeal (which would increase the spending limit a significant amount every year after 2006, leading to the eventual end of the cap on services);

• A splitting of the combined cap for SLP and PT services (although this is more of an ASHA-sponsored initiative).

"It is estimated that 13 percent to 15 percent of Medicare beneficiaries will exceed the therapy cap," predicted Moore. "Our goal is to reduce that number."

While talk of the cap dominated the three-hour session, issues such as the impending Medicaid reform, Medicare manual changes and skilled nursing facilities were also covered. Audience members were encouraged to participate, and discussion was lively throughout the event.

–By Rob Senior

Evidence-Based Reality

Translating evidence-based practice into the clinical setting

Nowadays the term is everywhere: Evidence-based practice.

PTs and PTAs hear it all the time, but what is it really? And how does it apply to what they do every day? In the June 9 session "Bridging the Gap from an Academic to a Clinical Setting," presenters Diane Jette, PT, DSc, and Shelley A. Goodgold, PT, ScD, looked into that question as well as explored how to bring evidence-based practice (EBP) into everyday work in a clinical setting. Jette, a professor and PT department chair at Simmons College in Boston, and Goodgold, also a professor at Simmons, presented a real-world approach to evidence-based practice.

Lost in Translation

The concept of EBP makes perfect sense: Using evidence as a basis to provide care. In the classroom, students of PT are given the opportunity to use evidence and research to approach treatment and evaluation. However, when they cross over into the clinical setting, it can sometimes be difficult to find the time or resources to provide the well-rounded care evidence-based practitioners strive for.

Jette and Goodgold addressed the subject of incorporating the evidence-based ideal into the reality of the clinic. "The evidence-based practitioner thinks about her practice all the time," said Jette.

The process of EBP starts with the individual patient. Based on the evaluation of the patient, the practitioner must formulate a clinical question, find evidence, critically appraise the evidence and finally, integrate the evidence into her individual practice.

However, the patient will have a good deal to do with how the evidence is integrated into the practice. Jette used the example of a patient with COPD who refuses to wear the supplemental oxygen in public. All available information may point to the same conclusion—that the supplemental oxygen is best for the patient—but if the patient is not going to use it, your research may need to be geared toward finding an alternative option.

"We can have the evidence, but we have to also consider the patient's values. Not everything is possible in every setting," said Jette. "We have to accept that there is not always a black and white, and we have to mix the science of PT with the art of PT."

Seek and Ye Shall Find

Sometimes the toughest part about being an evidence-based practitioner is finding the information. While there are plenty of studies and publications out there talking about a specific condition, it can take some effort to get your hands on the one article that will help you with your patient.

Both Jette and Goodgold went through an interactive demonstration of just how PTs can find the information and where to look for it. On PubMed's Website, attendees walked through a searchable index of articles.

The key to getting back the best results is the question, they related. The goal is to develop a question that best narrows the list of articles to a few that will be the most helpful for a specific patient's case.

When developing a question to put into the search, there are a few boundaries that, when set, can result in patient-specific articles. Some examples of such boundaries are population, treatment and outcomes. Additionally, the use of terms such as AND, OR and NOT can narrow the results to the area you are looking into. These general concepts help to make research a more efficient process.

Once the question is developed, searching within MeSH terms, or medical subject headings, is a convenient way to make sure all of the results fall into one specific category. For example, if a PT enters the overarching term of incontinence, the MeSH terms returned by the search will include urinary incontinence, stress urinary incontinence, fecal incontinence and many others. Keeping the search within one or two MeSH terms allows therapists to avoid the overflow of returns on a more general search.

Sometimes, even with the best question, a searcher may still come up with results that are questionable. Just because something is out there does not always mean it is accurate, Goodgold stressed. Evaluate the information presented. Is the methodology sound? Were the outcomes presented due directly to the treatment? Do the subjects of the research reflect your patient?

Although evidence-based practitioners may be aiming to learn something, Goodgold emphasized that it is also important to trust in what you know as well. "I think it's very important that you have faith in yourself. If you think there's a real flaw, you're probably right," she said.

–Stefanie Kurtz

Advanced Advocacy

Session discusses how therapists can take active steps to influence legislators

The APTA's Government Affairs Department was certainly busy during this APTA 2005 conference. Dave Mason, vice president of congressional affairs, presented the session "Strategies for the Statehouse," on June 9 along with Justin Elliott, associate director of state government affairs. Later that day, Mason spoke at the session, "Critical Issues in Congress for Physical Therapy," with colleague Justin Moore, MPT, PT, director of congressional affairs.

Mason and Moore were back at it the next morning, building on the previous two sessions with their presentation, "Strategies for Advanced Physical Therapy Advocates." Geared toward therapists who were already familiar with basic concepts of legislative advocacy, the session covered ambitious ground.

"I'm going to assume that everyone in this room is interested in grassroots initiatives," Mason told the assembled attendees. "This session will be about how to go to the next level in developing communication that works best with elected officials."

Initiating Practice Visits

In beginning his presentation, Mason extolled the benefits of inviting a local legislator to visit a therapist's personal practice, explaining how this action can educate the legislator and work better than visiting Washington, DC, for the purpose of lobbying.

"Capitol Hill is a hectic place," he noted. "The issues being discussed at the time you visit often aren't your issues. And that's OK, but it does limit the effectiveness you can have."

Mason added that when he joined APTA three years ago, he was surprised to discover even some of the organization's more experienced grassroots advocates weren't using their practice settings as the basis for their lobbying.

"The average member of Congress or state legislator has little previous experience with health care," he emphasized.

Benefits of Visit

Why invite a legislator to your practice? "Because your practice is a 'classroom,'" Mason commented. He outlined the following benefits:

• Your practice is a setting where health care policy meets real-life patient care;

• There are fewer distractions, obstacles and competition for the legislator's attention;

• The visit will build your relationship with your legislator;

• The legislator gets personal contact with your profession and patients.

"From your standpoint, they're patients," Mason noted. "But from the legislator's standpoint, they're voters."

Making It Happen

Having emphasized the benefits of a legislator visit, Mason addressed the steps necessary to make it happen.

"Get to know the district/local office, including the district administrator and scheduler," he said. "Outline your plan for the visit, including possible dates and the issues you want to cover. And most importantly, follow up!"

Patrice Winter, PT, a therapist and city council member in Fairfax, VA, joined Mason on the stage to offer her unique perspective as an "insider."

"It may seem scary at first to try and approach a legislator like this," she related. "But it is important to be passionate and have confidence in your knowledge of physical therapy. [When I was considering inviting a legislator to my workplace,] I came to realize that I was an expert in my field as a manual therapist. Legislators are regular people who want to do what's best for their constituents. But they have so much on their plate that they can't possibly know everything about everything. They need people like us to help them understand what the issues are and what they can do about them."

Get To Know Your Legislator

Winter emphasized the importance of getting to know your legislator before you try to influence his stance on an issue, however, not trying to do both at the same time.

"Every campaign office needs volunteers," she said. "[When I was contemplating advanced advocacy efforts,] I did not have the money to make campaign donations, so I volunteered at the local senator's office. You need to volunteer before the issues come up."

Mason agreed with this point. "I hear from therapists sometimes, 'I wrote a letter [to my legislator about an issue], I made a phone call and nothing happened.' Well, does that surprise you? The legislator has no previous awareness of who you are."

Organizing the Visit

If a therapist is fortunate enough to obtain a confirmation that the local legislator will come to his practice, the next step is organizing the visit.

"Focus on a single 'ask,'" Mason noted, as opposed to bombarding the legislator with several different requests. Also, execute the following steps:

• Make sure to conduct the visit yourself (Don't let others redefine your message);

• Emphasize the local anecdotes and information (how the situation impacts voters);

• Get pictures—hire a photographer if possible.

"It is very important to a legislator to have cameras there," Winter explained. "Getting a picture in a local paper means a lot. It provides advertising for your business and some media face time for the politician."

Inviting patients to be a part of the visit is also beneficial, Mason added. Choose patients who reinforce your message, and have them sign a HIPAA authorization.

"Planning is [vital]," Winter added. "I didn't have any patients there when a legislator visited my office about 10 years ago. In retrospect, I wish I did."

In some cases, press coverage may also be set up. Therapists can coordinate with the legislator's staff on these arrangements and even allow time for the legislator to make remarks for local journalists. Another preparatory aspect is rehearsing with colleagues and patients on these points:

• Making sure your visit plan can be trimmed if necessary;

• Being clear about who is presenting what information;

• Checking that patients are prepared for and comfortable with their roles;

• Ensuring the practice is tidy and colleagues are dressed professionally.

Conducting the Visit

When the day of the visit arrives, there are a few keys to remember in conducting it. Expect the unexpected. Be ready to make on-the-spot adjustments. When you've presented your case, look the legislator in the eye and ask directly for the action you want.

It is also important to balance your passion and advocacy for an issue by recognizing the other side of it, Mason added. Legislators must always be cognizant of both sides of an argument. It will help them to respect your viewpoint if you have looked at how the action you desire could adversely impact others.

Following Up

Once a visit has been completed, there are several steps involved in following up, Mason continued:

• Send a letter thanking the legislator and his staff for taking the time to visit;

• Reinforce your key points and ask again for the action you want taken;

• Send a personal note to your patients and colleagues who participated—with pictures;

• Keep in touch.

"These points are not optional," Mason emphatically stated.

The APTA's overall goals regarding practice visits include getting every legislator to visit a PT practice, encouraging coordination with colleagues in different settings, incorporating issue forums and campaign events, and promoting practice visits at component meetings.

"If you do set up a practice visit, tell [APTA]," Mason added. "We want to know that it happened, but more importantly, what the legislator said about where he is on the issue."

"And remember to call your legislative office [initially] when you can give something, not when you need something," Winter concluded. "From there, you can start to build your relationship."

–Brian W. Ferrie

Advanced Grassroots Cultivation

In the second part of the session, "Strategies for Advanced Physical Therapy Advocates," Justin Moore, MPT, PT, director of congressional affairs for APTA, took the stage to discuss "Advanced Grassroots Cultivation."

"There is no exact science to grassroots," Moore told the audience. "We spent a lot of time in the late 1990s and early 2000s spreading awareness about how PTs can get involved at the basic grassroots level."

The efforts were so successful, and so many PTs are now aware of what basic actions they can take, that APTA has begun to focus on more advanced initiatives.

"The first step of grassroots is knowing your congressman's name," said Moore. "The second step is him knowing yours."

There are three keys to grassroots involvement, he continued:

• Educating your members;

• Making people want to be involved;

• Taking that one-time involvement to a long-term relationship.

Moore also emphasized the five "R's" of building grassroots:

• Recruit (evolve to recruiting the "right" people);

• Retain;

• Recognize your grassroots personnel and show them their impact;

• Reward;

• Repetition (keep people active but don't burn them out).

With regard to the last point, it is important to space out action alerts, Moore noted. "The closer together two alerts are, the less impact the second one has."

Professionalism is vital to grassroots efforts, he added. "And the level of professionalism demonstrated by our grassroots personnel has been outstanding."

Physical therapists who are interested in becoming involved in grassroots activities should contact Michael Matlack in the APTA Government Affairs Department, Moore noted, at michaelmatlack@apta.org.

"[When it comes to grassroots efforts], time is often more valuable than money, especially at the local level," concluded Dave Mason, vice president of congressional affairs for APTA. "Campaign activity is what you want to make of it. If it's something you truly enjoy, there are enormous opportunities out there."

–Brian W. Ferrie

Home Sweet Home

Maley Lecture focuses on the homeless, and how PTs can help

There was a somber atmosphere surrounding the 10th Annual Maley Lecture, held on June 11 at the annual conference. Last January, John Maley, for whom the lecture was named, lost a brief but courageous battle with cancer.

APTA President Ben F. Massey Jr., MS, PT, offered a brief remembrance of Maley, before giving way to David Maley, John's son. In a touching tribute, David remembered his father as a man who "loved the physical therapy profession and cared greatly for its growth."

David Maley then introduced this year's lecturer, Jennifer M. Bottomley, PhD, MS, PT, president of the APTA's Section on Geriatrics. Dr. Bottomley began by thanking her predecessors and colleagues who led her into the home care setting, and declared that she was dedicating her lecture, "There's No Place Like Home: Providing Care for Underserved Adults" to the legacy of John Maley.

An Epidemic

Dr. Bottomley began by describing homelessness as a "transgression from our societal values." The natural reaction of many people to avert their eyes when happening upon a homeless individual is a prime example of both the alienation of the homeless and the discrimination inflicted upon this population by the rest of our society.

"As a society, we should be judged by how we treat our least, our last, and our lost," stressed Dr. Bottomley.

Dr. Bottomley gave a short history of the epidemic in America, showing how homelessness surged after the Civil War and again during the Great Depression, culminating in a migration of many homeless to urban areas throughout the 1970s.

What's more, homeless people over the age of 50 began falling through the cracks—not yet eligible for Medicare, they could not receive proper medical care. Today, in the state of Massachusetts alone, she related, there are enough homeless in the elderly population to fill a football stadium. Throughout the nation, more than 10 percent of the elderly fall below the poverty line. A lack of affordable housing often leaves such individuals with few alternatives.

With the recent controversy over Social Security in the country, it would seem that homelessness in the elderly population is doomed to become an even greater problem in the future. According to Dr. Bottomley's research, without the currently implemented Social Security system, nearly one-half of the elderly population would fall beneath the poverty line (compared to the current 10.5 percent.)

So, Dr. Bottomley asked, what can physical therapists do to help reverse these disturbing trends? "We need to establish better knowledge and offer education for risk factors," she urged.

Even homeless shelters are difficult for some elderly individuals to access due to mobility issues. Additionally, many of these shelters are open only at night. However, Dr. Bottomley saw this as an opportunity, suggesting daycare as a possible role. Perhaps by getting more PTs to work in this daycare setting, it would become possible to work with these individuals to help improve mobility and overall fitness.

Dr. Bottomley offered Boston's Long Island Shelter as an example. Currently, the staff at the shelter is augmented by more than 200 volunteers, with physical therapy—type screenings offered for biomechanics, mobility, cardiovascular health and the possible need for orthotics—all in a person's first visit.

However, due to factors like the ones mentioned above and others, the inconsistency of homeless adults coming to the clinic often means that first visit might be the last time the PT will see an individual. "Often, the PT has only one shot at performing evaluations and treating these individuals," said Dr. Bottomley.

Dr. Bottomley also cited such organizations as the Committee to End Elder Homelessness and the Anna Bissonnette House as means for physical therapists to get involved. On an even smaller scale, helping can be as easy as donating unnecessary or surplus items to a shelter. Dr. Bottomley herself confessed to scavenging hotel rooms for bars of soap and assorted toiletries to take back to shelters.

"We have only begun to skim the surface of how physical therapists can assist this population," Dr. Bottomley concluded. "By doing a little, we can help a lot."

–By Rob Senior

Taking the Reins

A look at family-friendly options in employment

While Elizabeth Wilcox was pregnant with her third child, her second child developed a blood disease that caused the child to stop producing enough platelets for his blood to clot. Wilcox decided at that point to stay home with her children until her family was "in a better place."

Grateful that she had a situation that allowed for her time away from her job, Wilcox decided to use the time to write a book for mothers about making their work lives more accommodating to their home lives. The Mom Economy, the product of her efforts, was the focus of the session "Getting Family-Friendly Work" that Wilcox presented on June 10 at the conference.

Taking Control

Wilcox addressed an interested audience about the challenges of taking control of your situation by taking into account your individual occupational considerations, financial considerations and familial considerations. "'Family-friendly' is a relative term," said Wilcox.

She went on to explain that in researching The Mom Economy, she spoke with hundreds of women each with her own personal and professional needs. Some of them found their jobs to be satisfying those needs, while others believed theirs fell short.

Wilcox took a look at the historical trends that have led women in professional positions to be in prime condition today to take on both a career and a family without taking away from either. After women began moving into the workforce, the progression continued toward employee-led changes. "The onus is now on us, as employees, to redefine the way we're working while not impacting [our] employers in how we do our jobs and our productivity," she said.

The Options for PTs

Although Wilcox is not a physical therapist, her research into PT led her to the conclusion that the field is a unique one. She found that on paper, PT is a field dominated by women in which employees who work part-time actually make more money than those who work full-time, and in which those with a bachelor's degree in PT make more money as well—at least for the moment.

According to Wilcox, in order to get family-friendly work, a person must first "understand your industry, profession and job responsibilities." She explained that professionals must also consider their options. Are they looking to stay with their current employer and make changes, start fresh with a new employer, or go into business for themselves?

Staying with your existing employer is often the best route, according to Wilcox. "It is much easier to propose family-friendly work to a company you've been working for already," said Wilcox. "They know your track record."

If you do choose to move to another job, Wilcox suggested some ways to get a feel for the company's opinion on outside life. She said while on an interview, look around the facility for personal items on desks. Listen for conversations around the office while waiting, or if you walk into the kitchen or restroom of the facility. Do the employees seem content? Also, she suggested asking interviewers what is the accomplishment they are most proud of in their own lives, to get a feel for what they hold as a priority.

For the individual looking to go into business for herself, Wilcox emphasized the importance of knowing strengths and weaknesses. She said that while self-employment can be a family-friendly option in that you can better control your schedule, there is the potential for added stress.

Above all else, Wilcox emphasized professionalism as a priority. For example, when proposing a family-friendly schedule to a current employer, it is imperative to do your homework. Examine if there are other like-minded employers offering the schedule you are looking for, and find out how it is working. When presenting the proposal, format it as a report including evidence to back up the claim that your proposed schedule will not negatively affect the organization in some way.

Contrary Conclusions

The session ended with a discussion about getting family-friendly work. The audience talked about how the demand for PTs all over the nation has opened the door for more family-friendly options. However, students in the audience mentioned how professors suggest that these options are not available. Some practicing PTs were hesitant to suggest the changes.

The audience did not consist only of mothers and mothers-to-be. There were also a number of managers and recruiters looking at this issue from the other side. The consensus seemed to be that family-friendly work is certainly an option–particularly in this shorthanded field–contrary to what PTs have been taught prior to going into the field.

–By Stefanie Kurtz

Pharmacology and Therapy

Considering the medication can make—or break—the treatment

The majority of patients PTs see are on some kind of medication at some point during treatment. But how does the pharmacological intervention effect the physical therapy treatment? A session on June 9 at the conference, titled "Clinical Pharmacology in Physical Therapy: How to Make Pharmacology Work for You," addressed just that.

Patient Meds

"If we can take a look at the meds our patients are on, we will better understand how to approach them," said presenter Ross Biederman, DPM-MD, from Azusa Pacific University in California.

Without considering the medications a patient is taking, therapists put themselves in a position to alter the outcome of treatment. When it comes to a patient's drug regimen, knowing a little bit about the medication can go a long way.

Getting the appropriate knowledge can be a challenge, though, when there are 600,000 drugs on the market. It would be virtually impossible to know everything about every drug. However, according to Dr. Biederman's findings, the average prescribing professional regularly uses about 20 drugs.

Dr. Biederman suggested that PTs become familiar with the generic names of the medications they see most often. The Physician's Desk Reference (PDR) allows therapists to look up a drug by the generic name, the brand name and a picture of the pill.

While the information found in the PDR is helpful, Dr. Biederman recommended being both aware and knowledgeable of information available outside of the resource. The information provided in the PDR is sponsored by the manufacturer of the drug. While this information is not inaccurate, it might be helpful to look at other resources in addition to the PDR information.

Dr. Biederman also emphasized that the effects of the brand name drug can be different than those of the generic version of the same drug. While sometimes the two can be identical, there are also times when, for example, different preservatives are used in the drug. It is important to recognize these differences, he explained, because it can affect how the patient responds to treatment.

What to Know

Dr. Biederman explained the specific information PTs should know about the medications their patients are taking. Details such as how the drug breaks down, what its half-life is, where it goes in the body and how long before it takes effect or for the effects to subside will help therapists best plan when to see the patient or what treatment options will work best.

In his presentation, Dr. Biederman explained that some drugs have a rapid onset while others have a slower onset. Medications that have a rapid onset are likely to have a rapid offset as well and anything with a rapid offset is more prone to withdrawal symptoms, he said. This can affect treatment of the patient.

Dr. Biederman also told the audience, "like likes like." In other words, the effects of the drug may be extended if the environment is ideal. Dr. Biederman used Ritalin as an example. A patient who is prescribed Ritalin for ADD may be more receptive during treatment if he is treated before the effect wears off. If a child taking Ritalin has a therapy appointment immediately after school and won't be taking the medication prior to coming in, it is possible he will be coming off of the drug's effects when he comes in to see you.

One way to avoid that issue is to request the child's mother be sure to pack a lunch with acidic foods like oranges or tomatoes to complement the ph level of the drug. "We are trying to encourage a thoughtful approach," said Dr. Biederman.

Fight, Flight or Flop

Dr. Biederman also suggested that PTs take note of is whether the drug's effects mimic those of the sympathetic or parasympathetic nervous system. The sympathetic system initiates fight-or-flight responses while the parasympathetic system will initiate calm.

This is important for PTs to recognize because if a drug has an impact similar to either system, it can result in a drastic change in patients' ability to fully participate in treatment. A drug that mimics the sympathetic nervous system's response can cause an individual to seem irritable or nervous and their blood pressure will likely go up, whereas stimulating the parasympathetic system can make a patient seem lazy or unmotivated.

Dr. Biederman emphasized that all of this can have an effect on the treatment plan, but being aware of the medications can put PTs in the position to better control the timing, duration and ultimately the level of success of treatment.

–Stefanie Kurtz

Home on the Rang

Session at PT 2005 focused on injuries among farmers and ranchers

Conference sessions on June 10 included a unique presentation in the category of cultural competence: "Home on the Range: Maximizing Quality of Life for Farmers and Ranchers Through Physical Rehabilitation and the USDA AgrAbility Project."

Presented by Millee Jorge, EdD, PT, Langston (OK) University, the session explored health in minorities and disparities in health among rural community dwellers. It also emphasized the effort to reduce potential health disparities specific to physical rehabilitation services and the ability to maximize quality of life for this special population.

Agrarian Nation

"The United States is an agrarian nation," Dr. Jorge began. "Farms and farm families remain powerful symbols in American culture. The American farm is a unique worksite because the farmer, family and friends are often together at home and at work."

The speaker delved into race and ethnicity in rural poverty, noting that based on the 2000 census, 17 percent of the non-metro (rural) population is comprised of racial and ethnic minorities, the non-metro minority population is growing in all 50 states, and overall U.S. poverty rates are higher for minorities than non-Hispanic whites.

Farming Trends

Farming has been in transition for several decades in this country. There were 7 million farms in 1935 compared to just 1.9 million in 1997, and the small farmer has seen his role decrease in the overall industry compared to the corporate farm. In fact, although 92 percent of U.S. farms are small farms, just 71 percent of the assets in farming belong to small farmers, and 67 percent of the land used for farming is owned by small farm owners. Despite constituting only 8 percent of farms in this country, large or very large (corporate) farms and non-family farms combine for 68 percent of the total farm production.

In moving on to farm culture, Dr. Jorge noted that farmers in general are independent, proud, responsible, stoic, skeptical of "new-fangled ideas," and may be female (27.5 percent) or from different ethnic or racial groups, such as white, black, Hispanic and Native American.

High Injury Risk

Farmers are also at high risk for injury.

"Farming is reported to be the most dangerous occupation in the United States, according to the National Safety Council," said Dr. Jorge. "Fatalities occur to young and old alike. The National Institute of Occupational Safety and Health (NIOSH) reports over 2 million people younger than 20 years of age are potentially exposed to agricultural hazards."

More than 200,000 people working in agriculture are injured annually, Dr. Jorge continued.

"Thousands incur permanent injury–long-term impairments and disabilities. An estimated 500,000 farmers, ranchers and farm workers have physical disabilities that interfere with their ability to perform their work."

Farm-related health issues include musculoskeletal disorders (e.g., overuse syndromes, arthritis, traumatic amputation), neuromuscular conditions (e.g., SCI, paralysis due to neurotoxic chemical exposure), cardiopulmonary issues (e.g., pulmonary irritants, chronic exposure to dust) and integumentary concerns (e.g., skin cancer, burns, frostbite).

AgrAbility Program

The AgrAbility Program was created in 1991 and developed nationally through the USDA when provision for the project was included in the Farm Bill of 1990. Its mission is to provide assistance to farmers and ranchers with disabilities and their families to allow them to continue farming/ranching.

Program objectives include providing education and assistance to accommodate for disability in farming, educating service providers who support AgrAbility clients, providing on-farm technical advice, and mobilizing volunteer resources.

The initiative has certainly made progress. There were eight states with AgrAbility grant awards in 1991, and by 2004 that number had increased to 24 states.

Farmers are grateful for the help, since many want to continue farming and residing on their land after an injury or illness, Dr. Jorge explained. In addition, farmers often work well beyond the typical retirement age of other workers, and farming and ranching generally do not become financially viable industries until the sixth and seventh decades of a person's life.

"The best thing we could ever do for somebody is offer them choices," concluded Dr. Jorge.

–Brian W. Ferrie