Post 75. PT in the ED

“Between 2000 and 2011, the number of ED visits in the United States rose by 26%, and this trend is expected to continue with implementation of the affordable care act.… Nearly 30% of hospital-based EDs have closed since 1990”
Essentially, this means that more and more people are using the emergency department, but staff sizes aren’t increasing as much as they should be according to the increase in usage. With the addition of the affordable care act, more people are insured. Although this sounds good, the reimbursement rate for providing the same service from last year has gone down this year.
Rant: this just chaps my ass. How many different businesses will allow the customer to pay less next year than they did this year? I would love it if the price of milk kept dropping year-over-year unfortunately for healthcare providers the value of saving lives has gone down year to year.

“…nearly half of all ED visits can be classified as semiurgent (35%) or nonurgent (8%).”

This means that the “emergency department” is no longer used for emergencies. This takes resources away from those that are urgent in order to treat those that are not as urgent. The article speaks of using ED physicians to treat sprains and strains, which could be treated by a primary care physician’s office.

 

“With increasing numbers of patients seeking care in EDs for nonurgent musculoskeletal conditions, physical therapists have the knowledge and skills required to play an increased role in the primary care of patients and to help mitigate overcrowding and improve time efficiency in the current ED environment”

This was a mouthful. The authors are making the assumption that the types of patients presenting to the emergency department will not change. This means that almost half of the patients coming into the ED do not actually need “emergency” services. Because of this, PT’s can play a major role in assessing and treating musculoskeletal conditions. Doing so would take the resources (emergency physicians) and allow these services to be directed towards the patients that need this service specifically. This would reduce wait times in the ED. Having been to the ED at times with my daughter (one of the prices of being a new parent), I totally agree that wait times can be a deterrent to going to the ED. For some problems though, we can’t wait.  

“This practice (physical therapists in the ED) was first described in the United States in 2000 and was identified as an ‘emerging practice’ by the American Physical Therapy Association.”

My specific hospital started using PT’s in the ED and I am proud to say that I was part of the catalyst for starting this program. We go up to the ED in order to assess spinal pain and balance/vestibular conditions. I find that our opinion is valued as a consultation by the ED physicians, but I have no objective data to back up that belief.

“Physical therapists function as secondary practitioners and require referrals from medical doctors to examine and treat patients”

This is true to an extent. PT’s in this state I practice require a referral in order to treat a patient, but not to evaluate a patient. This is not true for every state, as each state has its own practice act.  

“Physical therapist practice in the IUMH (Indiana University Methodist Hospital) ED began in 2002 with one full-time physical therapist…evaluate more than 2,000 patients annually”

In the hospital from the study, the article notes that the total number of hours of PT’s working in the ED has increased over time. This is not the case yet in our hospital, as the therapists are essentially “on-call” in the ED from their respective locations in the hospital. For instance, I work in the outpatient setting, but when there is need for a spine evaluation, I get called to go upstairs when needed/able.

“The reason for dissatisfaction reported in both cases (both from staff physicians) was that the ED physical therapist was not available at the time the physician sought to refer a patient”

This is the only reason for being dissatisfied?! This is a great sign for the future of PT’s in the ED.

“…the following 3 items were rated as most valuable in both 2004 and 2011: (1) provide specific instructions regarding the proper and safe use of assistive devices; (2) provide interventions that are an alternative to pain medication; (3) educate patients regarding injury prevention, safety, and body mechanics with daily activities.”

We look at gait training and think that it is easy. We are trained very well to do this and should take ownership over performing gait training and gait analysis. As PT’s, especially outpatient PT’s, gait training with an AD is something that should be done before a patient gets to outpatient, but this is a part of our profession. We should not allow other professions to own this. In taking ownership, this needs to be done for all patients that need the assistive device, regardless of setting.

Pain management seems to be pushed hard in the media now, as there is an opioid epidemic. As therapists, we can educate on the hurt vs harm mentality. Patients need to understand the difference. Unfortunately, pain can cause patients to become fearful. This places the patient into a cycle in which any activity that causes pain should be avoided. This will only prolong the cycle of pain.  

I don’t believe that there is any other profession that can assess body mechanics with as much depth as PT. 
The end result of the article is that physicians are pleased with PTs in the ED and note that PTs are the most qualified to assess body mechanics, gait training, and return to work. The chief gripe was lack of availability of PTs when requested. This is another avenue for hospitals to increase revenue, as this is considered an outpatient visit. 
Fruth SJ, Wiley S. Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive Comparative Analysis Over Time. Phys Ther. 2016;96:1333-13341

Post 75. PT in the ED

“Between 2000 and 2011, the number of ED visits in the United States rose by 26%, and this trend is expected to continue with implementation of the affordable care act.… Nearly 30% of hospital-based EDs have closed since 1990”
Essentially, this means that more and more people are using the emergency department, but staff sizes aren’t increasing as much as they should be according to the increase in usage. With the addition of the affordable care act, more people are insured. Although this sounds good, the reimbursement rate for providing the same service from last year has gone down this year.
Rant: this just chaps my ass. How many different businesses will allow the customer to pay less next year than they did this year? I would love it if the price of milk kept dropping year-over-year unfortunately for healthcare providers the value of saving lives has gone down year to year.

“…nearly half of all ED visits can be classified as semiurgent (35%) or nonurgent (8%).”

This means that the “emergency department” is no longer used for emergencies. This takes resources away from those that are urgent in order to treat those that are not as urgent. The article speaks of using ED physicians to treat sprains and strains, which could be treated by a primary care physician’s office.

 

“With increasing numbers of patients seeking care in EDs for nonurgent musculoskeletal conditions, physical therapists have the knowledge and skills required to play an increased role in the primary care of patients and to help mitigate overcrowding and improve time efficiency in the current ED environment”

This was a mouthful. The authors are making the assumption that the types of patients presenting to the emergency department will not change. This means that almost half of the patients coming into the ED do not actually need “emergency” services. Because of this, PT’s can play a major role in assessing and treating musculoskeletal conditions. Doing so would take the resources (emergency physicians) and allow these services to be directed towards the patients that need this service specifically. This would reduce wait times in the ED. Having been to the ED at times with my daughter (one of the prices of being a new parent), I totally agree that wait times can be a deterrent to going to the ED. For some problems though, we can’t wait.  

“This practice (physical therapists in the ED) was first described in the United States in 2000 and was identified as an ‘emerging practice’ by the American Physical Therapy Association.”

My specific hospital started using PT’s in the ED and I am proud to say that I was part of the catalyst for starting this program. We go up to the ED in order to assess spinal pain and balance/vestibular conditions. I find that our opinion is valued as a consultation by the ED physicians, but I have no objective data to back up that belief.

“Physical therapists function as secondary practitioners and require referrals from medical doctors to examine and treat patients”

This is true to an extent. PT’s in this state I practice require a referral in order to treat a patient, but not to evaluate a patient. This is not true for every state, as each state has its own practice act.  

“Physical therapist practice in the IUMH (Indiana University Methodist Hospital) ED began in 2002 with one full-time physical therapist…evaluate more than 2,000 patients annually”

In the hospital from the study, the article notes that the total number of hours of PT’s working in the ED has increased over time. This is not the case yet in our hospital, as the therapists are essentially “on-call” in the ED from their respective locations in the hospital. For instance, I work in the outpatient setting, but when there is need for a spine evaluation, I get called to go upstairs when needed/able.

“The reason for dissatisfaction reported in both cases (both from staff physicians) was that the ED physical therapist was not available at the time the physician sought to refer a patient”

This is the only reason for being dissatisfied?! This is a great sign for the future of PT’s in the ED.

“…the following 3 items were rated as most valuable in both 2004 and 2011: (1) provide specific instructions regarding the proper and safe use of assistive devices; (2) provide interventions that are an alternative to pain medication; (3) educate patients regarding injury prevention, safety, and body mechanics with daily activities.”

We look at gait training and think that it is easy. We are trained very well to do this and should take ownership over performing gait training and gait analysis. As PT’s, especially outpatient PT’s, gait training with an AD is something that should be done before a patient gets to outpatient, but this is a part of our profession. We should not allow other professions to own this. In taking ownership, this needs to be done for all patients that need the assistive device, regardless of setting.

Pain management seems to be pushed hard in the media now, as there is an opioid epidemic. As therapists, we can educate on the hurt vs harm mentality. Patients need to understand the difference. Unfortunately, pain can cause patients to become fearful. This places the patient into a cycle in which any activity that causes pain should be avoided. This will only prolong the cycle of pain.  

I don’t believe that there is any other profession that can assess body mechanics with as much depth as PT. 
The end result of the article is that physicians are pleased with PTs in the ED and note that PTs are the most qualified to assess body mechanics, gait training, and return to work. The chief gripe was lack of availability of PTs when requested. This is another avenue for hospitals to increase revenue, as this is considered an outpatient visit. 
Fruth SJ, Wiley S. Physician Impressions of Physical Therapist Practice in the Emergency Department: Descriptive Comparative Analysis Over Time. Phys Ther. 2016;96:1333-13341

Keeping the customer/patient happy

 

“…owners and managers an no longer rely solely on the relationships they have built with referral sources to grow their practices”

 

Look at the drug companies…they know how to peddle their wares. Once it became mainstream to advertise directly to the consumer we have what is now known as the “opioid epidemic”. If we can advertise directly to the consumer, and give the consumer what they want…business will boom. We have to know what the consumer wants first though. Don’t try to sell them what we have, know what they want and then create the product. We know that patient’s primarily want education first. Give them a taste of the education during a seminar and then tell them that they have to schedule an appointment in order to get the rest of the information. It’s funny. I remember working for Bill Curtis at PT and Spine and he would refer to the magic treatment. In that patients are looking for that magic so that way they can take control of their own issues. If one is the owner, we want to give the patient the magic…but not on the first day. If we got paid for outcomes and not for the patient coming to the clinic, there would be more incentive to help fix the patient at the initial visit and not carry it on for the national average of 8-16 visits for the average orthopedic issue.  

 

“Even five years ago physicians largely dictated our referral patterns…hospital-based clinics and physician-owned practices are aggressively attempting to keep their patients “in-house”.  

 

Everyone in business wants money. THEY WANT YOUR MONEY! There is incentive to keep you going to the same company for every service performed. If you need an MRI, X-ray, PT, sports physical, etc it is very convenient if it is all under one roof. Now, who is making the money? I’m going to make it easy. If your mechanic finishes looking at your car and then says that you need $10,000 dollars worth of work, but he can do it all at once, what are you going to say? What if I say that you need $20,000 worth of work? How high do I have to take that number before you realize that it may not be legitimate needs to continue? The doctors/hospitals that own all of the above “services” may be doing the same thing, but you never see the costs because the insurance “covers” the cost.

 

“We are aware that patients can choose to receive therapy wherever they would like…”

 

Are the patients aware of this? If you go to the doctor and get a referral for therapy (it’s like a referral to any other practitioner), but the referral has the name of a specific clinic on it, does the patient realize that they can still go anywhere? IF YOU ARE A PATIENT AND ARE READING THIS…YOU CAN GO TO ANY THERAPIST THAT YOU WANT TO GO TO! Not all PT’s have the same training or even the same specialty. If you don’t see progress with your therapist after 6 visits, and you are given the words “it just takes time”, find a new therapist. Some things do take time, but hear it from 2-3 different therapists before you actually believe it.  

 

“We are not here to ‘fix’ a patient; we are here to partner with them in their rehab”

 

This is huge. I don’t fix you…I help you fix yourself. I play the role of cheerleader, teacher, listener, advisor, but at no point am I the “fixer”. When I see you for 2 hours per week, there are so many hours throughout the week in which you have to help keep yourself fixed by what you learn in the clinic.  

 

I realize that I can come across as negative with regards to the business of healthcare and unfortunately it is more of a realistic view than either pessimistic or optimistic. I have had discussions with those that audit clinics, researched the Department of Justice website for healthcare fraud, shadowed/worked/observed in unethical clinics and have heard patient stories from their times in other clinics. My view is personal, but real. When I say get a second or third opinion, it’s because you may have to go through that many different clinics before you find one that has your intentions at the forefront.  

 

Excerpts taken from: Stamp K. Happy Customers: How to create a positive patient experience. IMPACT. July 2016:31-32.

 

 

Our we worth it?

“First, we must actually prove the value of our services, ourselves, and our profession. And we must do so objectively – with outcomes data. ”
I agree to a certain extent, that we need to prove our value with outcome data. Patients, so need to be educated on what this data actually means. We are slowly transitioning to a point in which patients are paying for a majority of their healthcare when compared to insurance companies. Co-pays are rising. Outcome data needs to be measured, but explained to patients in a way in which it makes sense. We do need to prove our value, but proving our value to patients will be completely different than proving our value to insurance companies.
“That that that tracking patient outcomes… The demand for this type of data collection has amplified in the last few months…”
The demand for this type of data is increasing from insurance companies. Do you think insurance companies are demanding this data in order to increase our pay? I highly doubt it. They’re demanding the data to determine whether or not therapy in actually valuable. I, as the therapist, sometimes question the value of physical therapy. Not all therapists practice alike, so is there one best practice? As a profession, we have clinical practice guidelines. Not all therapists are utilizing clinical practice guidelines. Can we weed out those therapists that are not using the guidelines, or can we coach up these therapist to ensure that they are practicing in a way that is supported by the evidence.
“… The federal government is not wasting any time and it’s quest to reduce healthcare spending that ”
We all know that our country is broke! if we ran our household in the same manner that our government runs the country, we would all be filing for bankruptcy. The government is trying to find ways to reduce costs. Healthcare appears to be one way in which to reduce costs. I am not saying I totally disagree, because as a country we spend a great deal of money on healthcare, but do not get the results commensurate with the spending. We have to find a way in which to incentivize good care to ensure that patients are no longer getting sick at the same rate they’re getting sick currently.
“So, in all likelihood, most – if not all – payments will be linked to value within the next few years quote
This same line has been stated year-to-year for at least the last six years. At some point I am waiting for the boy to stop crying wolf. I welcome the day when pay-for-performance actually takes place. Therapy consists more than simply ultrasound,hot pack, electrical stimulation, and massage. The best evidence we have is regarding exercise. It’s sad because not all therapist coming out of schools are proficient at analyzing, providing, and creating exercises in order to address the limitations seen during the initial valuation. I spend a great deal of time with the students that I have teaching them how to create and how to analyze movement patterns. They do not learn this very well in school.
“… There is a big difference between merely recording numbers and generating meaningful, actionable insights, because when you do the latter, you can achieve three really important things: ”
As a profession, we need to start by “merely recording numbers”. I started as a therapist in 2007, and during those first few years recording numbers was not happening. We have come a long way in utilizing functional outcome measures, but this is because insurance companies have forced our hand in order for us to receive payment. I do not believe that our profession would have policed itself into using outcome measures.
Excerpts from:
Jannenga H. IS PT VALUABLE? ONLY OUTCOMES DATA WILL TELL. IMPACT. June 2016: 46-51

Pinky and the Brain

 

shutterstock_266981183We all like to think of ourselves as important. “No one can do my job as good as I can.” We all think like this, or at least I hope we do.

 

  1. “One successful strategy for reducing the backlog of patients, developed in the United Kingdom, is for physiotherapists to screen patients referred by GPs before a first consultation with an orthopaedic surgeon.”

 

I wouldn’t have thought that this was possible in the US when I first entered the profession of PT, but now I at least think that it is plausible. There are many hurdles to overcome, and the first is money. If a surgeon is not seeing a patient, then the surgeon is not making money. The ideal of this scenario is to have surgical candidates see the surgeon and for non-surgical candidates to see non-surgeons.

 

On the flip side, therapists will have to become owners of the profession. I have worked with many PT’s that really enjoy the “paint by number” system, otherwise known as protocols, but protocols don’t necessarily fit in an environment like the one described. We have to be able to think independently and assess patients either using pattern recognition or using something like the Hypothesis Oriented Algorithm for Clinicians.

 

  1. “gatekeeper role for physiotherapists is supported by the growing body of evidence that it is effective, and that physiotherapy is an appropriate treatment for many musculoskeletal conditions”

 

As much as I agree with the statement that PT is effective, I don’t know if this statement supports the use for PT’s as a gatekeeper. I envision the role of gatekeeper as more of an assessor instead of a “treater”.

 

In the case of back pain, there are assessments that can be used prior to treating the patient in order to determine how much “help” the patient will need. When assessing the patient, there are odds ratios to determine a patient’s need for surgical intervention compared to conservative interventions.

 

These are the themes that a therapist must know in this type of setting.

 

  1. “In the UK, the initiative has resulted in reduced and more appropriate referral to orthopaedic surgeons, more timely interventions for those unlikely to benefit from surgery, and a shorter waiting time for appropriate care for all patients.”

 

This is very important. Just imagine that you need a back surgery for something very serious, such as an infection or cauda equina (just know that it is serious), but you have to wait in line to see the doctor because someone has a “pulled muscle” (not very serious). If those that are definite surgical candidates can get to see the surgeon faster, this would reduce the need for the surgeon to screen the patient in order to determine the next step.

 

In other words, if you have back pain, it is classifiable in about 80% of cases. Roughly 70-80% of those cases could be treated appropriately with PT initially. This would prevent about 56-64% of patients needing to see the orthopaedic in order to initiate treatment.

 

  1. “receives an average of 150 new referral each month to the orthopaedic outpatient department. Three orthopaedic surgeons and a registrar are available to screen 10 new and 18 review patients each week in one 3-hour clinic session…the waiting list for non-urgent care patients…waiting time of 164 weeks until their first appointment”

 

AND WE THOUGHT WE HAD TO WAIT A LONG TIME TO SEE THE DOCTOR! Think about this. If you had to wait over 3 years to see the doctor, would you rather wait that long or see a PT in a much shorter time? We are not at that point yet in our country, but it is coming. You will notice that you are seeing less of your MD and more of your PA’s and APN’s. There are not enough physicians to take care of all of the patients that want to see the doctor. The net question is would your rather see an expert or non-expert for your problem. There was a study, that I will go back and find to write about at a later date, that shows in terms of minimal competency, only orthopedic surgeons and PT’s pass a basic test for musculoskeletal conditions. Again, why would you want to see any one other than these two professionals for a musculoskeletal problem?

 

  1. “Conditions considered for inclusion were musculoskeletal-related knee, shoulder or back pain (with or without leg pain)…excluded if their subjective history suggested any sinister disorder requiring urgent medical attention, or if they had psychosocial issues that contribute to symptom chronicity”

 

This study essentially compared a PT’s ability to assess patients to that of an orthopedic surgeon. I don’t know how much I agree with this because we are calling the orthopedic surgeon’s assessment the gold standard, but for lack of a better tool…it will have to do. To be fair, it was the only profession that scored higher than PT’s in terms of musculoskeletal competency.

 

  1. “The physiotherapy screening appointment involved a comprehensive assessment, a provisional diagnosis and the development of a management plan in consultation with the patient…reported to the patient’s GP by letter in the same week, and a copy of the letter was filed in the patient’s medical record.”

 

This is where the rubber meets the road. The PT’s had to assess the patient nd diagnose the patient. Good luck with that in the states. Until we have a greater influx of DPT’s the idea of diagnosing is more like a dream. We have been pre-programmed that the physicians (MD’s, DO’s) diagnose and we give a “physical therapy diagnosis”. WTF! We have the knowledge, but not the cajones! Instead, we tell you what the problem is, but won’t tell you for fear of stepping on toes.

 

Because our profession is not a direct access profession, such as chiropractic care, we depend on physicians’ referrals to physical therapy. If we upset the physicians, we may see those referrals decrease in overall number.

 

  1. “ Principal outcome measures of the preliminary study were:

-proportion of new referrals not needing to see a surgeon;

-the level of agreement between the physiotherapists and the orthpaedic surgeon on diagnoses and management decisions, and

-the patients’, GP’s and surgeon’s level of satisfaction with the physiotherapist-led screening initiative”

 

In my opinion, this is also listed in terms of order of importance. If we can cut down on the number of referrals not needing to see the surgeon, then we will effectively make the health care experience more efficient. This is the new buzzword in healthcare.

 

If we can agree with the surgeon’s diagnosis, that is good, but we are making the assumption that the surgeon is correct.

 

Finally, is the satisfaction of all involved in the study. This may be biased, as a doctor may not be satisfied with another professional taking point on a medical case.

 

  1. “The orthopaedic surgeon agreed with 74% of the management decisions made by the physiotherapists…differences only in differentiating back pain of mechanical or nerve root origin, and knee pain of cartilage or articular origin.”

 

This is good, but not great. This only states that we both agree with each other. The good thing is that there is not much of a difference between seeing the therapist or the surgeon in regards to the diagnosis.

 

  1. “experienced, well qualified physiotherapists can competently and safely undertake screening of patients referred to public hospital orthopaedic outpatient clinics with non-urgent musculoskeletal pain”

 

This bodes well for our profession and health care in general, especially the financial aspect of health care costs. Unfortunately, giving PT’s full, unrestricted access to patients is not on the horizon in the US.

 

  1. “In the current climate of health care workforce shortages, there is a growing interest in allied health professionals undertaking additional tasks in extended roles. Two-thirds of the patients screened in this trial did not need to see a surgeon at the time of referral, but required non-surgical care, predominantly physiotherapy and exercise.”

 

With the shortages of MD’s, there is an increased need for other professionals to fill that gap. Physical therapy is one profession that can manage the orthopedic aspects of the MD shortage.

Socialized what?!

 

We all have our own opinions regarding socialized medicine, but let’s just look at some of the research from countries that provide socialized medicine.  This article is based on the system in Australia.

 

  1. “…34-year old male referred by his GP (primary physician) to the orthopaedic outpatient department…carpal tunnel” The PT referred the patient back to the GP and “suggested that the GP organize nerve conduction studies to confirm carpal tunnel syndrome, before the patient would be offered an appointment with a surgeon…seeing a physiotherapist to help clarify the diagnosis and see if the symptoms would respond to conservative treatment”

This is a mouthful. Let’s start with some of the major differences between the Australian system and the US system. The PT is the gatekeeper to see the surgeon. The PT’s opinion or consultation was taken seriously and the patient was sent back to the primary physician to order the tests before seeing the surgeon. Keeping it simple. Therapists do therapy. Chiropractors do chiropractic. Surgeons do surgery. It is wasteful to send a patient to a surgeon if the patient does not need surgery. It is not efficient to send a patient to a surgeon to order more tests. Also, the PT would help to clarify the diagnosis. For a long time, therapists in this country have been treated like technicians, only capable of performing the treatments that the physicians deemed appropriate. This is simply not the case anymore. We are a doctoring profession. Not that this in and of itself places us on a pedestal, but some of us continue to expand our knowledge base and have become professionals at both movement and classification of patients. This is to be respected, sought after and rewarded…not necessarily monetarily, but at least with more opportunities to demonstrate our abilities.

 

  1. “initially assessed by another outpatient phsyiotherapist…computer worker with a four to five year history of altered sensation in the left upper limb;including numbness, pins and needles and pain in the hand and thumb, and, pain around the lateral aspect of the elbow…gradually worsening…using his left hand less in everyday activities.”

By the by, this was session one, which we will call day one. Again, the body is a roadmap. Symptoms that are referred to the hand can come from anywhere that sends information to the hand. Let’s break it down in laymen’s terms. When you flip the switch on the lamp and the light doesn’t turn on, what’s the problem? First, the light may be burned out. This is akin to the muscles not working appropriately or a problem at the location of the visual or perceived problem…in this instance the hand. The problem could also be the power cord. This is similar to a problem coming from a nerve that travels from the hand up to the neck. Any of the nerves that supply the hand could be “frayed”, for lack of a better term. Finally, the cord could be unplugged. In this case, the electricity isn’t even making it to the power cord. This is similar to a problem with the neck. If the brain can’t send the signal appropriately to the power cord, then the hand won’t work correctly.

This is obviously becoming a problem for this particular patient, as he is slowly de-emphasizing the use of his left hand.

 

  1. “full active and passive range of motion. Left shoulder flexion produced pins and needles in the left hand”

When a patient raises his arm overhead, most people can see how the muscles work and that the shoulder joint must be moving somehow. What people don’t see is how this plays on the nerves of the body. When a patient reaches forward, this pulls on the nerves of the body and sometimes can increase a patient’s symptoms.

 

  1. “Session two (two weeks later): non-dermatomal distribution of hand symptoms…the presence of night pain that consistently disturbed the patient’s sleep”

Red flags. Think of the JAWS theme music when you here these words. Red Flags are BAAAD! Non-dermatomal patterns means that the symptoms don’t match the road map of the spine. If a problem is coming from one location, it would typically refer to one location in the hand. If it is coming from multiple locations, then it would refer to multiple locations in the hand. Ever heard of the phrase “Occam’s razor”? This means that the simplest solution is typically the correct solution. Two separate lesions in the spine occurring at the same time is not a very likely solution. This indicates that there could be a space occupying lesion (AKA SPINAL TUMOR!). Second, the patient is waking during the night due to symptoms. This is also a red flag for…CANCER!

This is two weeks later and the suspicion of non-mechanical pain (AKA spinal tumor) is introduced. This is where timeline starts to play a role between socialized medicine and US healthcare.

For those that don’t know, this topic is close to my heart, as I am currently working on a paper for submission regarding a similar topic.

 

  1. “After 10 repetitions full active ROM had been restored in all directions. ULTT was pain free and full ROM with both median and radial bias”

MDT is known as Mechanical Diagnosis and Therapy. The Mechanical portion of this means, “what happens to the patient when we move the patient?”

In this case, the patient’s mechanics (ability to move) improved in all directions. ULTT (upper limb tension tests: pulling on the nerve to test their irritability) had improved after performing retraction and extension. When we see that a patient is improving with a treatment, we first assume that whatever we did actually helped the patient. I mean why wouldn’t it? It’s not like we think that we are special, but we do our best to be objective and not bias the patient to say that this treatment made me better. If the patient improves, then The puzzle is solved. If the patient tells me that they improved, but actually didn’t, then I did a poor job of establishing patient alliance! There has to be openness between the patient and therapist. Some research actually shows that patients will tell the therapist what they want to hear instead of what is true. I hope that this doesn’t happen to me, but then I would be fooling myself. As a therapist, I can’t help you 100% if the patient is not 100% truthful.  Okay, now back to our regularly scheduled broadcasting.

 

  1. “Session Three (one week later)…reduced elbow pain during the day and no elbow pain at night, fewer pins and needles, but the numbness in his fingers was unchanged…(at the end of the session) Numbness in the hand remained unchanged”

At this point, we are at three weeks and the third session. Don’t get me wrong, I like this style of therapy in which the patient is given a homework assignment and then return to the clinic for the PT to problem-solve the symptoms. Our current system has the patient coming to therapy 2-3 times per week for 4 weeks. I’m sorry, but if we look at normal healing for most musculoskeletal issues, it is six weeks! Think about that. We know that it could take up to 6 weeks to treat an injury and you will be coming to therapy for up to 12 visits and still not enough time has passed in order for an injury to heal. We know this, but as I stated in previous blog posts, healthcare is big business.

The patient’s numbness is unchanged at the end of the session, but all else is better. At this point, the therapist has to start to think that the numbness is non-mechanical and start doing differential diagnosis internally as to why the numbness remains unchanged.

 

  1. “Session four (two weeks later)…’bad week’ as he (the patient) had intermittently increased left arm pain “after sneezing and coughing”…numbness was unchanged.”

We are now at 5 weeks and the patient is unchanged. One of the red flags that is in the research is no improvement following 30 days of treatment. At this point, medical assessments should be advised and the patient should be scheduled for that surgical consultation.

 

  1. “Session five (four days later)…’better’ after the previous session…ongoing numbness in his left fingers…an appointment was arranged with an orthopedic surgeon…requested that an MRI of the cervical spine (neck) to investigate the possibility of spinal canal/foraminal narrowing and to examine the possibility of a compressive lesion or space-occupying lesion”

We are now at 6 weeks. In America, this would be about 12-18 sessions instead of 5 sessions. We would still be at the same end-point, but the cost savings would equate to about $1,300 over the course of the episode. Healthcare is a business, so return on investment has to be looked at. We get reimbursed roughly 100$/session from Medicare. It makes sense that the cost of healthcare continues to increase when a patient is coming into therapy based on traditional treatment paradigms instead of current evidence or even best practice.

Now this patient is moved along in the healthcare system. Something to note is that the PT can request the MRI in order to look for foraminal narrowing (STENOSIS) or space occupying lesion (TUMOR).

 

9 “Session six (two weeks later)…symptoms were generally worse in the evening and better during the day…numbness and pins and needles in the hand were intermittent”

Two months out and the patient is waiting to see the surgeon and get the MRI. This is a downfall of the socialistic medicine. If this is something very serious, then the patient has waited 2 months for the MRI. Is there a right answer? I don’t know, but I know that our healthcare system is broken and a shift to a more conservative type of healthcare may be worth a shot.

 

  1. “surgeon’s clinic approximately three and a half weeks after his last physiotherapy session. MRI of neck and nerve conduction studies of the left arm were ordered…MRI four weeks later…”abnormality of the entire cervical cord”…solid, cystic mass within the cervical cord from C4-C6…excision of tumour approximately four weeks later”

This guy had a huge tumor. This accounts for symptoms extending in such a large location, as the tumor affects the nerve roots (think multiple electrical outlets) from varying locations. This would explain the widespread symptoms in the hand. Again, let’s look at the time table: we are now about 3 months out from session one and the patient is finally in surgery.  I have seen a similar presentation in practice a couple of times and not all were favorable outcomes. I say this from experience, as I have had two patients that died from a similar presentation, which was caught well before 3 months after the initial assessment. The patient in the case survived and his symptoms improved after the surgery.

  1. “The wait to see the surgeon was a reflection of the large caseload within the orthopaedic surgeons’s outpatient clinic. The wait for the initial MRI was due to the prioritization system used by the medical imaging department, to manage demand for so called ‘non-urgent musculoskeletal’ MRI’s”

When everyone has the same insurance, everyone has the same access to healthcare. When everyone has the same access, there are not enough practitioners to go around and systems need to be developed to handle the overload of patients coming into the health care system. We are starting to see this impact of “Obamacare”. There are so many more patients coming into the system the past two years that it is not uncommon to have a 2 week wait to see the therapist for the initial evaluation.

MORAL: When everyone has the same right to health care, then no one has the same freedoms as they did previously, unless they choose to pay a portion of their healthcare out of pocket. This is doing what’s best for society at the cost of the individual. More people will be insured and have access to treatment. If I am the person that has a spinal tumor though and has to wait for 3 months for treatment…I don’t think that I am agreeable to this type of system.

Let me know what you think? Are you in a country with free healthcare, how does it affect you personally?

 Excerpts taken from:

 

Schoch P. Cervical spine tumor presenting as unilateral upper limb symptoms. IJMDT. 2009;4(3):24-29.

For more information or to receive an MDT evaluation from a credentialed therapist, I can be found at:

Functional Therapy and Rehabilitation

903 N 129th Infantry Dr

Joliet Il 

815-483-2440