Abstract
Background Limited research exists on the utilization and payments of physical rehabilitation services, especially among individuals with commercial insurance.
Objective This study aimed to characterize the utilization and payments of office-based physical rehabilitation services among nonelderly individuals with commercial insurance from New York State.
Design This was a retrospective descriptive study with a cross-sectional design.
Methods A cohort of 1.8 million individuals in the 2012 Truven Health MarketScan Research Database was constructed for review. A total of 109,821 unique patients who received any type of physical rehabilitation provided by physical therapists, chiropractors, and physicians in the office setting were included for analyses.
Results Physical therapists provided the largest proportion of physical rehabilitation services (54.5%), followed by chiropractors (27.5%) and physicians (18.0%). Six out of 100 individuals used physical rehabilitation services in 2012. The mean annual payment of physical rehabilitation per patient was $820 (median=$323). Women and older individuals were more likely to use rehabilitation services and have higher annual utilization and payments. For the 5 most common physical rehabilitation services, payment rates for chiropractors were the highest and those for physical therapists were the lowest, with payment rates for physicians in between.
Limitations This study was based on commercial insurance claims data from one state.
Conclusions Findings from this study recognize that rehabilitation services are delivered by various types of health care professionals and the payment rates vary across provider specialties in New York State. Of particular interest is that although physical therapists provide the largest proportion of services, their payment rates are lower than the rates for chiropractors and physicians. Future research should assess regional variations and explore interprovider cost-effectiveness in delivering these interventions.
Physical rehabilitation services can be used to restore, maintain, and promote optimal physical function.1 Evidence suggests that physical rehabilitation can reduce pain, alleviate disabilities, improve physical function, and improve quality of life for individuals with neck pain, low back pain, and osteoarthritis of the hip and knee.2–7 According to the 2010 National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), physical rehabilitation was ordered or provided at 28.2 million physician office visits.8 The Affordable Care Act of 2010 aims to extend health insurance coverage, foster greater efficiency in health care delivery, and improve patient safety and quality of care.9 The law also mandates coverage for essential health benefits, including rehabilitation services. A better understanding of the physical rehabilitation delivery system is an integral part of this effort.
Currently, little is publicly revealed about the actual physical rehabilitation services delivered to the general population, providers providing such services, and payments of these services. There are 2 limitations with existing studies. First, some studies have evaluated physical rehabilitation services rendered by physical therapists only.10–12 However, as in many other states, New York State education law allows for the performance of physical rehabilitation services by other professions whose enabling laws authorize such practices.13 For example, physicians may personally perform and bill for physical rehabilitation services. They also are permitted to submit claims for services furnished by nonphysician staff (including physical therapists) who are an “integral, although incidental, part of the physicians' personal professional services in the course of diagnosis or treatment of an injury or illness” (the “incident to” rule).14 Moreover, chiropractors may perform and bill for physical rehabilitation services, such as therapeutic exercises, neuromuscular re-education, and gait training, in addition to performing chiropractic procedures (98940–98943).15 Thus, a more accurate depiction of utilization and payment patterns requires an analysis of various provider types billing for such services. Beattie et al16 compared physical rehabilitation utilization of patients receiving workers' compensation for a musculoskeletal condition across a number of practice settings. The authors did not restrict the services to a specific type of provider. However, they excluded cases with more than one episode of care and those who received treatment from more than one facility. As a result, it is impossible to gauge the discipline-specific utilization rates for physical rehabilitation services in the study.
Second, prior studies assessing physical rehabilitation utilization and payments used the Medical Expenditure Panel Survey (MEPS) data.10,11 Compared with estimates from claims data, the total spending and the distribution of annual per-person spending were 10% lower when calculated based on MEPS data.17 A comparison of MEPS and the National Health Expenditure Accounts (NHEA) showed that the MEPS-based estimate for personal health care spending was 17.6% lower than the adjusted NHEA total.18 A series of outpatient therapy utilization reports commissioned by the Centers for Medicare & Medicaid Services (CMS) presented detailed information on the utilization and expenditures of outpatient physical rehabilitation services based on Medicare outpatient therapy claims data.19–21 However, the study sample was limited to Medicare beneficiaries. More research is needed to assess the utilization and payments of physical rehabilitation services provided by different providers in the nonelderly population. This lack of information limits policy makers' ability to make informed decisions regarding health planning and service delivery. It also prevents payers and policy makers from developing targeted interventions for providing cost-effective physical rehabilitation services. For example, reference pricing is a health plan design in which patients who use “designated” in-network providers agree to cap their fees at a predetermined price and patients are responsible only for their usual cost-sharing fees. Alternatively, patients who use “nondesignated” providers are responsible for any amount above the reference price, in addition to cost sharing.22
To address the information gap, the aim of this study was to document the utilization and payments of office-based physical rehabilitation services rendered by physical therapists, chiropractors, and physicians. This study contributes to the body of knowledge by using claims data from a large cohort of commercially insured individuals across all sex and age groups. Compared with prior studies, we provided new evidence regarding the service volume, diagnostic categories, and payments that providers received for physical rehabilitation services. As public and commercial payers move from a fee-for-service system toward a value-based payment system (eg, pay for performance), an in-depth understanding of real-world delivery patterns of physical rehabilitation services is valuable for establishing a value-driven health care delivery system.
Method
Study Sample
The primary data source for this study was the 2012 Truven Health MarketScan Commercial Claims and Encounters Database for the state of New York. This database reflects actual treatment patterns of employees, dependents, and Consolidated Omnibus Budget Reconciliation Act (COBRA) continuees with employer-sponsored primary coverage.23 Individual-level enrollment information is linked with payment data for outpatient service claims that come from a selection of insurance companies, Blue Cross and Blue Shield plans, and third-party administrators. The database has been the data source for a large number of studies published in peer-reviewed journals.23
The current study evaluated variables such as age, sex, procedure codes, diagnosis codes, provider type, and payment variables. In order to obtain detailed information about the content of physical rehabilitation services, this study focused on office-based professional claims. Physical rehabilitation services were identified using the Current Procedural Terminology (CPT) codes (97001, 97002, 97010–97799) that are located in the “Physical Medicine and Rehabilitation” section of the American Medical Association (AMA) CPT manual.24 For the majority of facility claims submitted by institutions, such as inpatient hospital and hospital outpatient departments, physical rehabilitation CPT codes were missing. Instead, revenue codes (eg, 0420–Physical therapy, general classification) were used. Therefore, physical rehabilitation services rendered by institutional facilities were not included in the analysis. An internal MarketScan variable (provide type) on the claim record was used to identify the type of providers who billed for the service. Considering that physical therapists, chiropractors, and physicians billed for most physical rehabilitation services (96.6%), this study focused on services provided by these 3 types of providers only. Because occupational therapists and speech-language pathologists (speech therapists) also bill for 97xxx codes, we excluded all the patients who received any occupational therapy and speech-language pathology services using specific CPT codes.
The study sample consisted of individuals who were continuously insured by employer-sponsored health plans for the 2012 calendar year and resided in New York for at least a portion of the study period. We restricted our analyses to noncapitated service claims because utilization and financial information on partially or fully capitated claims may not be complete. We excluded individuals with any occupational therapy and speech-language pathology services during the study period. We also excluded patients with claims of zero or a negative number of service units or negative payments because such claims may be adjustment records. Furthermore, individuals with a claim line payment rate ≥99th percentile were excluded to reduce the influence of extreme values on payments (Figure).
Study sample development flow diagram. OT/SLP=occupational therapy/speech-language pathology services.
Utilization Measures
Forty-three physical rehabilitation CPT codes were grouped into 8 broader physical rehabilitation service types (eTab. 1). Utilization of physical rehabilitation services during the study period was measured using utilization rates: volume of each type of physical rehabilitation service per 1,000 covered individuals, number of patients receiving each type of service per 1,000 covered individuals, and number of patients receiving at least one type of service per 1,000 covered individuals. Utilization rates broken down by sex and age groups also were reported.
Intensity of Physical Rehabilitation Services
Intensity of physical rehabilitation services was estimated by examining the annual number of service units received by a patient, the annual number of visits (operationalized as distinct service dates), the duration of physical rehabilitation (in days), and the total annual payments. We calculated the mean and standard deviation for each measure. Because the distributions were positively skewed, we also report the median and interquartile range (IQR). When compared with the mean values, medians are less likely to be affected by extreme values.
Associated Diagnoses
The primary International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes reported on the claims were recorded as medical conditions addressed by physical rehabilitation services. The diagnosis codes were aggregated to the Agency for Healthcare Research and Quality's (AHRQ) Clinical Classification Software (CCS) categories (single level) to obtain a smaller number of broader diagnostic categories.25 Diagnostic categories were further aggregated because some groups had few patients (eTab. 1). We also analyzed diagnostic categories associated with physical rehabilitation services by sex and age groups.
Payment Analysis
We calculated mean payment rates for physical rehabilitation services at the CPT code level. The analyses were based on the payment amounts that providers ultimately received from commercial insurance companies and patients for these services, in contrast to reports that focused on charges.
Data Analysis
Utilization rates are presented per 1,000 individuals. For intensity of physical rehabilitation services, we reported mean, standard deviation, median, and IQR for each outcome measure. We used chi-square tests, relative risks (95% confidence interval [CI]), one-way analysis of variance, and Kruskal-Wallis tests to assess the statistical significance of differences across different subgroups. All statistical tests were 2-sided, with a significance level of .05. Data management and statistical analyses were performed using SAS software, version 9.4 for Windows (SAS Institute Inc, Cary, North Carolina).
Role of the Funding Source
This study was funded by a grant from the New York Physical Therapy Association. The funding source did not have any role in study design, data collection, analysis, interpretation, manuscript preparation, or decision to submit the manuscript for publication. None of the authors had any obligation to report or share research findings before publication.
Results
This study included 1,827,028 individuals under the age of 65 years with noncapitated health plans in 2012. The study sample accounts for 10.9% of the estimated 16.8 million nonelderly residents in New York.26 A breakdown by age group and sex indicates that the study sample represents 10.0% to 12.2% in different subgroups (eTab. 2).
After excluding those patients with capitated service claims, with any occupational therapy and speech-language pathology services, we identified 129,754 individuals with at least one physical rehabilitation service claim billed by a physical therapist, chiropractor, or physician. We further excluded patients with claims with service quantity ≤0 or payment <$0 or payment rate ≥99th percentile. In the end, we identified 109,821 unique patients who received physical rehabilitation services. There were 2,555,733 claim lines and 1,104,085 service dates associated with these patients. Based on the number of service units, physical therapists provided the largest proportion of services (54.5%), followed by chiropractors (27.5%) and physicians (18.0%). At the patient level, 46.5% of patients who received any office-based physical rehabilitation services were treated by physical therapists exclusively, 28.7% were treated by chiropractors exclusively, 18.1% were treated by physicians exclusively, and the rest (6.7%) received services from 2 or more types of providers. Because services billed by physicians may be performed by physical therapists working in a physician's office, physical therapists' service volume is likely to be underestimated.
Physical Rehabilitation Volume
During the study period, the most commonly performed physical rehabilitation service in the office setting was therapeutic procedures (1,074 units/1,000 individuals), followed by supervised modalities (171 units/1,000 individuals), constant attendance modalities (103 units/1,000 individuals), physical rehabilitation evaluation/re-evaluation services (44 units/1,000 individuals), active wound care management (4 units/1,000 individuals), tests and measurements (2 units/1,000 individuals), orthotic management and prosthetic management (1 unit/1,000 individuals), and other rehabilitation services (less than 1 unit/1,000 individuals). A further look at the service CPT code (eTab. 1) shows that the 5 most commonly performed services were therapeutic exercises (97110), manual therapy (97140), neuromuscular re-education (97112), electrical stimulation (97014, supervised modality), and ultrasound therapy (97035). Particularly, therapeutic exercises (97110) accounted for 41.0% of the services provided by physical therapists, 24.2% of the services provided by chiropractors, and 33.6% of the services provided by physicians (data not shown).
At the individual level, 60 out of 1,000 individuals received at least one unit of physical rehabilitation service in the office setting over the study period. Therapeutic procedures remained the most common physical rehabilitation type (52/1,000 individuals). The second most common type was physical rehabilitation evaluation or re-evaluation (32/1,000 individuals), followed by supervised modalities (16/1,000 individuals), constant attendance modalities (12/1,000 individuals), active wound care management (1/1,000 individuals), tests and measurements (1/1,000 individuals), orthotic management and prosthetic management (1/1,000 individuals), and other unlisted services (fewer than 1/1,000 individuals). Overall, more than half of the patients (52.9%) received physical rehabilitation evaluation or re-evaluation services. Among patients treated by physical therapists exclusively, the number was 85.1%. By contrast, fewer than 1% of the patients treated by chiropractors exclusively had such a service on record. For therapeutic procedures, supervised modalities, and constant attendance modalities, the numbers of service units substantially exceeded the number of patients who received such services, indicating physical rehabilitation patients received multiple units of service during the year.
There is an apparent sex difference in the utilization of physical rehabilitation services. Women were more likely to receive physical rehabilitation evaluation or re-evaluation (relative risk=1.30; 95% CI=1.28, 1.32), supervised modality (relative risk=1.20; 95% CI=1.18, 1.23), constant attendance modality (relative risk=1.23; 95% CI=1.20, 1.26), therapeutic procedure (relative risk=1.22; 95% CI=1.20, 1.23), and orthotic management and prosthetic management (relative risk=1.13; 95% CI=1.01, 1.26). The sex difference in the relative risk of using active wound care management (relative risk=1.00; 95% CI=0.93, 1.08), test or measurement (relative risk=1.08, 95% CI=0.96, 1.22), and other unlisted physical rehabilitation services (relative risk=1.15; 95% CI=0.73, 1.81) were not statistically significant, probably due to the small number of patients who underwent such services.
Age was an important factor in the utilization of all types of physical rehabilitation services. The proportion of individuals with any form of physical rehabilitation increased substantially with age (Tab. 1). Among individuals aged 17 years or younger, 2.4% received physical rehabilitation services. This number almost doubled among individuals aged between 18 and 34 years (4.8%). In individuals aged 35 to 64 years, 7.4% to 9.5% received physical rehabilitation services.
Utilization of Physical Rehabilitation Services by Sex and Age Groupa
Intensity of Physical Rehabilitation Services
On average, a patient received 23 units of physical rehabilitation services within 10 visits in a year. The mean treatment duration was 84 days (calendar days between the start date and the end date). The overall mean annual payments of physical rehabilitation were $820 (Tab. 2). The median values for the measures were more moderate. The median number of service units in a year was 11, the median number of visits was 6, the median duration of physical rehabilitation was 38 days, and the median annual payment was $323. For all of the 4 intensity measures, the differences across sex and age groups were statistically significant based on nonparametric Kruskal-Wallis tests. Women tended to use more service units, make more visits, have longer duration, and incur higher payments of physical rehabilitation services compared with men. In general, the intensity of physical rehabilitation significantly increased with an increase in age. Patients aged between 55 and 64 years received the most service units, had the most visits, experienced the longest duration, and incurred the highest annual payments among patients in all age groups.
Intensity of Physical Rehabilitation Servicesa
Associated Diagnoses
More than 70% (ie, 71.4%) of patients who received physical rehabilitation were associated with 5 diagnostic categories (Tab. 3): spinal disorders (29.7% of the patients), sprains and strains (11.4%), connective tissue disorders (10.5%), nontraumatic joint disorders (10.2%), and musculoskeletal deformities (9.6%). These 5 diagnostic categories also were most common in all sex and age subgroups, with one exception. For patients aged 17 years or younger, the 5 most common diagnostic categories (accounting for 67.4% of patients) were sprains and strains, nontraumatic joint disorders, spinal disorders, traumatic joint disorders and limb fracture, and musculoskeletal deformities. In other age groups, sprains and strains were less common, whereas spinal disorders were ranked on the top of the list. Among patients aged between 55 and 64 years, the 5 most common diagnostic categories were spinal disorders, connective tissue disorders, nontraumatic joint disorders, sprains and strains, and musculoskeletal deformities. These 5 most common categories accounted for 67.3% of the patients, which indicates that patients in this age group had more diverse diagnoses. The definition of diagnostic categories and the count of associated claims are presented in eTable 3.
Diagnostic Categories Associated With Physical Rehabilitation Services by Sex and Age Groupa
Payments of Physical Rehabilitation Services
The mean payments of the 5 most commonly performed services were $43.57 for therapeutic exercises (97110), $32.98 for manual therapy (97140), $32.31 for neuromuscular re-education (97112), $19.47 for electrical stimulation (97014, supervised modality), and $17.86 for ultrasound therapy (97035), respectively. Payment rates for services billed under identical CPT codes varied substantially across 3 provider types (physical therapists, chiropractors, and physicians). For all of the 5 most common physical rehabilitation services, the mean payment rates for chiropractors were the highest, followed by those for physicians, with mean payment rates for physical therapists being the lowest (Tab. 4). The only exception was the mean electrical stimulation (97014, supervised modality) payment rate for physical therapists ($13.40), which was slightly higher than the mean rate for physicians ($13.23).
Physical Rehabilitation Payments by Provider Typea
Discussion
As the prevalence of musculoskeletal conditions such as low back pain and neck pain increase in modern societies,27–29 physical rehabilitation plays an increasingly important role in treating patients with these conditions. This study characterized office-based physical rehabilitation utilization and payments among commercially insured individuals. In a large cohort of individuals with commercial insurance from New York State, physical therapists provided the largest proportion of physical rehabilitation services, followed by chiropractors and physicians. Therapeutic procedures, including therapeutic exercises and manual therapy, were the most commonly performed service type. During the study period, 6.0% of the individuals had at least one physical rehabilitation visit. A patient, on average, received 23 units of physical rehabilitation services in 10 visits that spanned 84 days. The mean annual payment of physical rehabilitation was $820. Women and older individuals were more likely to use physical rehabilitation and were associated with higher intensity levels. Spinal disorders, including low back and neck pain, were the most common diagnostic category associated with physical rehabilitation services. For the 5 most commonly performed services, payment rates varied substantially by provider specialty type. To our knowledge, this study is the first claims data analysis that examined physical rehabilitation utilization and payments in a population across sex and age groups.
The payments of physical rehabilitation services observed in this study corroborated previous reports.10,11,30,31 In our cohort, the mean number of physical rehabilitation visits per year was 10 (median=6), and the total annual payments were $820 (median=$323). Machlin et al11 reported that the mean number of visits per episode was 10 (median=6) and the total payments per episode in 2007 were $1,184 (median=$651), which included the expenses for physical rehabilitation services received in both a physical therapist's office and hospital outpatient department. The results would be similar if they calculated annual measures because most patients had one episode in that study. Spinal disorders, connective tissue disorders, and sprains and strains were some of the most common diagnostic categories in our cohort. Similar patterns were reported by Pendergast et al.31
Our analysis demonstrates that utilization rates and intensity levels of physical rehabilitation services increase dramatically with age. Although, on average, 6.0% of the cohort received any form of physical rehabilitation service over a year, the number increased to 7.4% for individuals aged between 35 and 44 years, 8.2% for individuals aged between 45 and 54 years, and 9.5% for individuals aged between 55 and 64 years. Further research is warranted to identify the major drivers of physical rehabilitation service utilization in older age groups. As the population ages, the demand for physical rehabilitation will continue to rise.
Our study also shows that women were more likely than men to use physical rehabilitation services and receive more intensive treatment. Although it is unclear in the literature why women utilize physical rehabilitation services more often than men, some factors can potentially explain this disparity. Previous research on both neck pain and osteoarthritis has documented a higher prevalence in women compared with men.32–34 As the life expectancy of the population continues to rise, the number of women with osteoporosis and the prevalence of osteoporotic fractures in women will increase, which may further enlarge the sex gap of physical rehabilitation utilization.35
We reported both mean and median intensity of care measures in this study, and the overall and subgroup mean values were greater than the median values. This finding implies that physical rehabilitation utilization and payment measures are positively skewed and the means are strongly influenced by heavy users. As a result, it may be more appropriate to use medians to characterize utilization and payment patterns. Additionally, for all 4 of the intensity measures, statistical tests of means were not able to detect the difference across sex groups, whereas nonparametric tests could detect such differences. This finding further supports the use of median utilization and payment measures.
Our study provides valuable new data on payments of physical rehabilitation services. Professional payments of identical CPT codes varied substantially across provider types (physical therapist, chiropractor, and physician). For all of the 5 most common physical rehabilitation services, the payment rates for chiropractors were the highest and those for physical therapists were the lowest, with payment rates for physicians in between. Variation in payment rates across provider types may relate to discount arrangements between payers and providers. It is possible that different providers share the same relative value units for a service but use different contract agreement conversion factors to calculate payments. Presence of claim payment logic (eg, multiple procedure payment reduction), bundling logic (eg, a single lump payment for multiple providers in an episode of care), per-visit rate, and therapy benefit limitations also may affect the actual payments. Further research is needed to examine potential causes for the variation in payment rates. In addition, payment rate discrepancy across provider types may have an unexpected impact on the delivery and billing of physical rehabilitation services. For example, higher physician payment rates may prompt physicians who employ physical therapists to bill under “incident to” provisions rather than obtaining an individual provider billing status for the physical therapist.
Although a common practice in the literature,16,31 using CPT codes included within the 97xxx series may underestimate physical rehabilitation services provided by providers other than physical therapists. For example, in New York State, chiropractors are allowed to bill for physical rehabilitation services. However, few chiropractors billed for physical rehabilitation evaluation or re-evaluation service (represented by CPT codes 97001 or 97002). In practice, chiropractors and physicians may use evaluation and management service codes (99201–99205 and 99211–99215) in place of physical rehabilitation evaluation or re-evaluation service codes. The underlying reason may be that some insurance companies require the provider to be a licensed physical therapist to bill CPT code 97001.36–38 It is difficult, if not impossible, to distinguish evaluation and management codes related to physical rehabilitation from ordinary evaluation and management codes using claims data, which was beyond the scope of the current study. Additionally, osteopathic manipulative treatment codes (98925–98929) and chiropractic manipulative treatment codes (98940–98943) can be used by physicians and chiropractors to bill some rehabilitation services not listed in the “Physical Medicine and Rehabilitation” section of the CPT manual.
This study had limitations of note. First, although the sample population amounts to 10.9% of the population in New York and 18.4% of those with employer-sponsored health insurance,39 it is not a random sample of the population in general or those with commercial health insurance. For example, employees of small employers are not included.17 The patterns in utilization and payments of physical rehabilitation services may be different in a state other than New York or at the national level due to geographic variation in care-seeking behavior, medical practice, payment policy changes, and supply of health care providers.19,40,41
Second, the analyses were restricted to information reported in submitted claims. Limitations associated with administrative databases are well documented in the literature.42 Coding practices, billing errors, payment denials, and mistakes in claim processing may bring bias to claims data. Specifically, payment information was derived from claims adjudicated by insurers. In-network providers may bill a prenegotiated amount on claims, which may not fully reflect the usual charges. Out-of-network providers may balance bill patients, and such payments would not be captured using claims data.
Third, benefit package, cost sharing, fee schedule, and billing guidelines vary greatly across different payers and plans, which may affect physical rehabilitation utilization and payments. For example, some plans may cover only 20 visits of physical rehabilitation services per year, and preauthorization is required for visits beyond that. Most commercial insurance companies accept physical rehabilitation services billed by chiropractors, whereas Medicare reimburses only chiropractors for the manual manipulation codes (98940–98943) and will not cover any other services.14 In addition, patient cost sharing in forms of deductible, co-payment, or coinsurance may affect service utilization patterns. Therefore, it is necessary to examine the effects of these payer- and plan-level factors on the utilization, delivery, and billing of physical rehabilitation services. Unfortunately, identities of insurance companies and their plans were concealed in the MarketScan Research Database to protect business-confidential arrangements between insurance companies and providers. We were not able to assess the effects of certain payer or plan characteristics on the utilization and payments of physical rehabilitation services in the study. In the future, efforts should be made to ensure accurate documentation of physical rehabilitation services. Improved claims data are needed to support research that assesses the appropriateness of physical rehabilitation services (eg, guideline adherence).43,44
In conclusion, despite the above-mentioned limitations, this study provides valuable information on the utilization of office-based physical rehabilitation services, diagnostic categories, and payments among the commercially insured population in New York State. The results shed light on the fact that physical rehabilitation services are delivered by various types of health care professionals, and the payment rates vary across provider specialties. These findings lend the context to ongoing discussions about physical rehabilitation services. Future research should assess regional variations and explore interprovider cost-effectiveness in delivering these services.45
Footnotes
Dr Liu gratefully acknowledges Xuehui Li and Andrew Meng for their invaluable assistance on this project.
This study was determined to be exempt by the Institutional Review Board at the University of Central Florida.
This study was funded by a grant from the New York Physical Therapy Association.
- Received January 30, 2015.
- Accepted December 4, 2015.
- © 2016 American Physical Therapy Association
Reference
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