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Outpatient Therapy Services Payment System

Physical therapy services are performed by someone licensed in the physical therapy profession. This can either be a licensed physical therapist (either a Bachelor, Master, or Doctor of Physical Therapy) or a licensed Physical Therapist Assistant (Associate degree).

Aspects of our profession that are performed in the clinic are as follows:

therapeutic exercise: exercises performed in order to help a patient improve function, strength, endurance, range of motion and/or reduce pain

Neuromuscular re-education: training movement patterns, balance, coordination, kinesthetic sense (where the body is at in space during movement), posture, and proprioception (where the body is at during one moment in time)

Manual therapy: using ones hands or tools to perform massage, joint mobilization (moving individual or groups of joints), traction, passive ROM (using hands to move a joint through its range) in order to improve pain, range of motion, swelling or other restrictions

These are the most common interventions used in my clinic. Other interventions used are modalities (which may or may not have evidence to support the intervention and may or may not be covered by an insurance plan). Some are as follows:

Ultrasound

Electrical stimulation

Heat/cold

Mechanical Traction

Iontophoresis

Laser therapy/light therapy

This is still a grey area for many Physical Therapists (PTs). Although the rules are very straightforward, some clinicians never read the rules that insurance companies impose to the clinicians. When a clinician is treating a patient and is in-network with the insurance company, the PT is accepting the rules imposed by insurance companies. Medicare will pay for medically necessary services.

It is up to the PT to establish this necessity in the documentation. The PT the. Needs to have a physician or other allowable non-physician provider (think nurse practitioner) sign off on the initial documentation, which establishes the PTs plan of action/treatment/care. This plan of action must establish a few details and is valid for up to 90 days.

Let’s talk numbers. Our spending on outpatient therapy services (occupational therapy, speech therapy, physical therapy) is more than many countries spend to run the entire country. This is a very large number and insurance companies, both public and private, are trying to cut down on the total expenditures over time.

It makes sense, because expenses have increased by 6% year to year for the previous years.

It may come as a shock to many patients, but “outpatient” benefits can be used in an inpatient setting 🤫.

If you were in a nursing home, they may have used your outpatient benefits to pay for part of your rehab. This may not be the best use of your funds as seen Here and Here.

Surprisingly hospital outpatients use fewer funds than I suspected. It has been documented that many physicians are pressured to keep a patient “in-house”. This means that physicians are not “supposed to” refer a patient out of the hospital network. This keeps all of the money within the hospital to find profits. This was highlighted in a previous news Article

In a way, I’m not surprised that private practices see such a large amount of the Medicare pie, as it’s been noted how many are abusing the system for large payouts. Such as this company that settled for $7M for performing abusive practices. These practices are very common to see in the field of PT.

Patients with Medicare are only to be billed for non-group services (which by the way pay at a much lower rate), when they are actually seen one-one.

Also, patients are only to be seen by licensed professionals. This means that technicians (techs) or aides are not allowed to guide a patient through their exercise program, at least if the company plans to bill for these services. Don’t believe me…here’s another Example.

So I guess that I am not surprised by how much money is spent in outpatient settings.

Many patients don’t understand that sessions are typically billed by the “15 minute rule”. This essentially means that for every 15 minutes, or at times the better half of 15 minutes (8 minutes), that the patient will see a charge on their explanation of benefits or receipt for services.

For example, a patient may see 3 separate charges for a session if the patient was seen in the clinic for 45 minutes. It can get messy if this is not explained to the patient.

The amount of money that Medicare reimbursed is different for different areas of the country. This is based on how much the cost of performing business is within a certain locale.

Those that have Medicare have to pay 20% of accepted/fee schedule amount.

This is where things can get confusing. For instance, I’ve seen an average visit (1 hr) be charged from $360-$1200 to the insurance company. This is a huge range in charges, which is also a problem with our healthcare system because it makes it difficult for patients to understand the actual charge.

Out of the charge for an hour, Medicare will allow close to $100 depending on how that hour was broken up into charges. The other $260-1100 is written off as an “adjusted” amount based off of insurance “savings”. (This savings number is also arbitrary to make it look like you get a great deal from having insurance).

Of the $100 that is allowable, the patient is responsible for 20% of that charge. The patient can choose to have another entity, a Medicare supplement or secondary, pay the other 20%. Of course the patient has to pay a monthly premium, unless on state aid, for that other 20%.

This is a way for business to start gaming the system. They will start to shorten session lengths so that they don’t lose as much money per session. There are three separate components that go into what is allowable by Medicare. They cut one of the three components by 50%.

Companies are then shortening sessions to the least allowable to maximize charges, such as shortening sessions to 25 or 40 minutes in order to maximize their reimbursement per session. They will then keep the patient coming in for more sessions per week in order to maximize payment.

Sometimes it’s what’s best for the patient, but many times it’s only what’s best for the company.

Those companies that charge more, or are in the upper tier of chargers in our profession. For instance, in our state their was a company that was audited and asked to pay back over $600K to Medicare due to inappropriate charges.

The article can be found Here

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Start Back Screening Tool

“Lifetime prevalence for LBP (low back pain) has been reported to be between 60% and 95% and 34% of the participants in a large population study in Norway reported to have had LBP last week”

These numbers are scary, but are consistent with other published research that notes about 80% of the population will have back pain at some point in life. Think of how lucky you would have to be to go an entire lifetime without having back pain based on these numbers?

It can happen, as I’ve seen patients in their 80’s with a first time occurrence of back pain.

The part that is sad for me, as a PT, is that less than 10% of these people will ever get in to see a PT for back pain.

“Due to the lack of diagnostic tests that can identify objective signs of the condition, most of the patients are characterized as having ‘non-specific LBP'”

If you’re not familiar with the numbers, it has been said that any diagnosis trying to name a specific tissue (disc herniation, arthritis, spondylisthesis, spinal stenosis etc) is only correct about 10% of the time. The more severe the diagnosis the more likely that the specific tissue is the correct diagnosis (such as a tumor, spinal cord injury, infection).

Because of this, a majority (90%) of back pain is just labeled as “non-specific low back pain”. The problem with this is that the treatment for a non-specific problem tends to be…non-specific.

Don’t get me wrong, a majority of back pain doesn’t need much treatment, if any at all, and tends to improve over the course of 6 weeks. Some pains from the back require a specific treatment and a treatment outside of this Specific treatment can worsen symptoms.

This means that we have to actually attempt to classify a patient’s presentation. Understand please that a classification is not a diagnosis but instead more of putting the symptoms into a non-specific “bucket” that most resemble that presentation. For instance, there could be a bucket for fast changing, slow changing and unchanging. There could be buckets for a primarily psychosocial component, chemical component or a bio mechanical component.

“Based on the SBT (Keele Start Back Tool) scores, patients can be categorized into three subgroups: patients with low, medium, or high risk for developing persistent LBP and activity limitations….the low risk group should receive minor attention from health professionals and self management strategies are recommended for these patients. The medium risk group should be offered physiotherapy. For the high risk group more psychologically informed interventions are recommended”

This statement may upset some of my colleagues in PT, but we aren’t always needed for patients that experience back pain. For instance, it is advocated to see a PT if you have pain lingering more than a couple of Days. I’m not sure I completely agree with this, as much back pain reduces spontaneously. The last thing you, as the patient should want is to pay for unneeded treatments. The last thing that I want to do as a PT is to take a patients money if I am not needed at that time.

Again, don’t get me wrong there is a group of patients, with back pain, that should be treated by a Physical Therapist. These patients will score higher on the Start Back Screening Tool.

With that said, it is important that the patient be classified correctly within the first 6 weeks of experiencing symptoms. Some research demonstrates an early classification is beneficial and others demonstrate that it should be done within 6 weeks of symptoms. The reason for this is that the patient may benefit from more psychologically informed interventions, which should be performed by someone with

“To be useful as a screening tool in physiotherapy practice, it is important that the SBT-scoring is reliable and that the allocation to risk groups reflects the severity of the patients back problems.”

There are two things that we look at in terms of performing testing. One, is the test valid. This means does the test actually tell us what we think it tells us.

The second thing is reliability. This means that if I have multiple therapist from different settings performing the same exact task, would I get similar or exact scoring if performed on the same exact patient by different therapists.

“The SBT consists of nine items; referred leg pain, comorbid pain, disability, bothersomeness, catastrophizing, fear, anxiety, and depression…. The total score range from 0 to9, with nine indicating worst prognosis. The last five items are summarized into a psychosocial sub scale with five as the maximal score, indicating high risk for development of chronic LBP”

For more information about scoring, I personally like to use the Shirley Ryan website of outcome measures found here.

“Patients with a total score of 0-3 are classified as low risk (minimal treatment, eg self-management strategies).

I use this tool frequently in PT. I rarely have patients score a 3 or less, but this may be because they are already filtered out by the physician in primary care.

I recently had a patient score a 3 and lo and behold his symptoms were abolished in 6 weeks without intervention.

It’s a small sample size, but it seems to match the research.

To summarize: the STarT Back Screening Tool is an option to utilize in practice in order to determine if a patient

1. Requires little/no intervention and will return to prior level of function (PLOF) through regression to the mean (time > interventions).

2. Requires PT/Rehab only

3. Requires a more psychologically intensive approach to care.

Click here for original research article.

STarT Back Screening tool revisited

“…changes in psychosocial risk factors during the course of treatment may provide important information for a patient’s long-term prognosis”

As professionals, we should be performing repeated assessments of patients during the plan of care (POC) and not waiting until the patient is ready for discharge (either because their benefits have been exhausted, the insurance company dictates that an assessment needs to be performed or the patient self-discharged). Performing repeated assessments throughout the POC allows us, as professionals, to understand if the patient is improving, worsening or remaining unchanged with care and to assist us in modifying the POC.

The STarT Back Screening Tool is one method of assessing psychosocial factors that may impede rehab potential.

“… repeated assessments during an episode of care can also provide valuable information about changes in a given variable that can be used for treatment monitoring”

Utilizing a standardized approach to assessing a patient will enable the professional (PT in my case) to determine if a patient is catastrophizing, losing hope, or requires the assistance of a more psychologically focused treatment approach.

“The STarT Back Tool (SBT) is a Screening questionnaire consisting of nine items related to physical and psychosocial statements that are used to categorize patients based on risk (low, medium, or high) for persistent LBP-related disability.”

Here is a copy of the tool in question.

“Wideman et al found that early changes in SBT scores were predictive of four month treatment related changes in several relevant psychological and clinical outcome measures.”

This is a little different than what is expected from an outcome tool. For instance, many tools are utilized to tell the clinician where the patient is at currently and if this patient Hs a risk of developing chronic pain.

When we utilize multiple scores instead of a standalone score, this is indicative of how a patient will progress over the course of time.

“all patients (in this study) were referred for physical therapy by a physician and did not seek physical therapy services through direct access… this setting was considered secondary care.”

This is an important topic. For instance, the previous blog post indicated that the tool gives us information when read minister over a 4-week time period. This indicates that there are changes that occur over the course of 4 weeks.

Many complaints of low back pain improve independently over the course of 6 weeks. If a patient is issued this test at the first visit and classified as low, medium or high, this may lead to an inaccurate classification. Seeing as this study issued the tool to patients in a secondary care (meaning that the patients were referred by a physician) indicates that the patient is not being seen within the first few days of injury.

“1. Aged 18-65 years,

2. Seeking physical therapy for LBP (symptoms are T12 or lower, including radiating pain into the buttocks and lower extremity), and

3. Able to read and speak English”

“treatment was not standardized or tracked in this study and was provided at the discretion of the physical therapist.”

This may also be an issue, as there is a newer study that indicates the treatment interventions may have a role in the patient’s scoring.

Please see the previous post about how to utilize this tool.

“…123 patients (84.2% of the entire sample) who completed the SBT at intake and 4 weeks…The percent of patients for each SBT risk category who were classified differently at intake and four weeks was 81.8% for SBT high risk, 76.0% for SPT medium risk and 11.3% for SBT low risk.”

This indicates that a patient’s initial score should be interpreted with caution because there is a high probability that it will change over the course of 4 weeks.

“most patients either improved (48.8%) or remained stable (40.6%) based on changes in SBT categorization.”

“Thirteen (10.6%) patients were categorized as worsened based on changes in SBT categorization, with six of those patients categorized as SB team high-risk at intake and four weeks later.”

This is interesting to me. Typically, in PT, a therapist will cite regression to the mean. This essentially states that given time the patient will transition from an extreme score towards a more moderate score. This doesn’t account for those that transition from a moderate score towards a more extreme score. To me, this indicates that the episode of care had an effect, albeit a negative effect, on this patient encounter.

Primary findings of this present study were as follows:

1. At over 4 weeks, approximately 11% of patients worsened SBT risk;

2. Clinicians should be less confident in the stability of an intake SBT categorization of high risk than that of medium and low risk;

3. Prediction of 6-month pain intensity scores was not improved when considering intake or 4-week change for SBT categorization; and

4. Prediction of 6-month disability scores was improved when considering intake, 4-week, and 4-week-change SBT categorization”

This indicates that the first measurement may not be a good indication of what will take place with the patient regarding disability over time and some patients can be made worse with therapy. We already knew the second part from previous blog posts.

Excerpts from:

Beneciuk JM, Fritz J, George SZ. The STarT Back Screening Tool for Prediction of 6-month Clinical Outcomes: Relevance of Change Patterns in Outpatient Physical Therapy Settings. J Orthop Sports Phys Ther. 2014;44(9):656-664.

Clinical Practice guidelines for Bell’s Palsy

Let me start by saying that I have seen few cases of Bell’s palsy comparatively. I can say I’ve seen no more than 10 cases in 12 years and reading this practice guideline, I can understand why it’s not a large percentage of patients seen in the clinic.

This post will be linked to the next blog post on Bell’s palsy because there are some conflicting recommendations, but not dramatically different.

“Bell’s Palsy, named after the Scottish anatomist, Sir Charles Bell, is the most common acute mononeuropathy…most common diagnosis associated with facial nerve weakness/paralysis”

I enjoy history. I didn’t know about Sir Charles Bell and I found this piece informative. Whenever a new disease or species is found, sometimes the discovered of the new xyz gets to name the new xyz. It is one way to keep their name alive. It could’ve also been described according to the actual dysfunction, as facial nerve palsy would indicate to everyone what is happening to the patient.

Once you see a patient with Bell’s palsy, it is never forgotten. The dysfunction can have dramatic effects on patients in terms of livelihood and willingness to go out in public.

People close to me know that I am a huge wrestling fan. One of the greatest, if not the greatest announcer in the history of professional wrestling is Jim Ross. His was the first time that I can remember learning of Bell’s palsy and it’s possible that his diagnosis cost him his job. It’s at least written about in other forums that there is a relationship. It was a long time before I got to hear about slobberknockers on tv again. Jim is back to work and his disease is visible to those that look close enough at his face.

“…rapid unilateral facial nerve paresis (weakness) or paralysis (complete loss of movement) of unknown cause.”

I have seen this run the gamut from barely noticeable to unable to close the eye or mouth. At the worse end of the spectrum, the person had major issues with drinking because there was incomplete mouth closure, which caused liquids to spill out of the mouth. Also, the same person was unable to move the eye or cheek muscles. An eye patch was required.

“…may cause significant temporary oral incompetence and an inability to close the eyelid, leading to potential injury”

With issues of mouth and eye closure, imagine how hard it is to keep the eye moist. Blinking assists in lubricating the eye, not to mention that the eye has difficulty producing moisture from the gland in the corner of the eye in the presence of Bell’s palsy.

“Treatments are generally designed to improve facial function and facilitate recovery”

The patients that I have seen, remember only a handful, I believe that only one person improved. At no point in time do I take credit for that, as a majority of patients improve over the course of 3 months. This patient was referred to me at the 6 week mark and time may have been more important than anything I did regarding the patients recovery.

“…the following should be considered:

-Bell’s palsy is rapid onset (<72 hours)”

I’ve had patients associate Bell’s palsy with a cold breeze blowing on them at night. They say this because the onset is so quick that some literally woke up with it. The patients attempt to find answers for why things happen. As a healthcare provider we have to do our best to educate and reassure the patient that it was nothing that they did to cause this phenomenon.

-“Bell’s palsy is diagnosed when no other medical etiology is identified as a cause of the facial weakness”

This is a diagnosis of exclusion. As mentioned at some point in this article, differential diagnosing needs to be performed in order to ensure that there is nothing sinister or other diagnosis causing this problem.

-“bilateral Bell’s palsy is rare”

I have personally never heard of bilateral Bell’s palsy and have obviously never seen it with my low level of experience treating this issue.

-“Currently, no cause for Bell’s palsy has been identified”

This has to be stated to patients. They will matrix and try to come up with a cause, which can create a change in behavior and the spreading of “old wives tales”. The most common one I hear is that the window being open caused a breeze while sleeping, or a fan was blowing on my face causing a breeze, to cause the symptoms.

-“other conditions may cause facial paralysis, including stroke, brain tumors, tumors of the parotid gland or infratemporal fossa, cancer involving facial nerve, and systemic infectious diseases including zoster, sarcoidosis, and Lyme disease”

These are all major issues that require a thorough history and possible imaging to determine if Bell’s palsy is the true diagnosis or if there is something obvious causing symptoms.

-“Bell’s palsy may occur in men, women, and children, but is more common in those 15-45 years old; those with diabetes, upper respiratory ailments, or compromised immune systems;or during pregnancy”

It affects both genders (I’ve seen both men and women), a wide age spectrum (I’ve never seen anyone older than 50) and multiple comorbidities can increase risk.

“…paresis/paralysis typically progresses to its maximum severity within 72 hours of onset of the paresis/paralysis”

This is good to know as a PT. It’s rare for us to see these patients in the acute, or immediately after it starts, stage. Because of this, should we see a progressively worsening condition, it would be prudent to refer the patient back to the physician in order to rule out any other medical concerns.

“Facial paresis or paralysis is thought to result from facial nerve inflammation and edema”

This is one of the explanations, but again there is no known cause.

“The facial nerve carries nerve impulses to muscles of the face, and also to the lacrimal glands, salivary glands, taste fibers from the anterior tongue, and general sensory fibers from the tympanic membrane”

This can cause the corners of the mouth to droop. The person may be unable to fully close the mouth to suck out of a straw.

The lacrimal glans is the little pink thing on the inside of the nose-side of the eye. This gland is responsible for keeping the eye moist.

“…may experience dryness of the eye or mouth, taste disturbance or loss, hyperacusis, and sagging of the eyelid or corner of the mouth”

Because it also supplies “power” to the tastebuds, this can affect taste. I’ve known many patients of those that I treated that lost weight because food was no longer appetizing.

“Most patients with Bell’s palsy show some recovery without intervention within two to three weeks after onset of symptoms, and completely recover within three to four months”

This is a very important statistic. Without knowing this, a patient referred to PT within days of the diagnosis, whom shows improvement within weeks, may lead the PT to believe that physical therapy has more significant effects than actually occurs.

“… facial function is completely restored in nearly 70 percent of Bell’s palsy patients with complete paralysis within 6 months and as high as 94% of patients with incomplete paralysis”

This information must be highlighted with patients. The effects of this diagnosis can be dramatic the first few weeks and hope needs to be restored in these patients.

Good ol JR is back to announcing wrestling!

“…as many as 30% of patients do not recover completely”

This needs to be addressed, but the education needs to be flipped to show that 70% recover partially or fully.

“Long-term, the disfigurement of the face due to incomplete recovery of the facial nerve can have devastating effects on psychological well-being and quality of life”

Two patients that I have treated in my past avoided going outside. Not to paint them in a negative light, but they lived like the Hunchback of Notre Dame. These two needed positive reinforcement in order to return to a life outside of the home.

I felt bad that these two have excluded themselves from the community because they wanted to return to normalcy, but didn’t want to be stared at in the process.

“…patients with facial paralysis can have impaired interpersonal relationships and may experience profound social distress, depression, and social alienation”

“The guideline is intended for all clinicians in any setting who are likely to diagnose and manage patients with Bell’s palsy”

As a PT, I will only discuss the information that is relevant to my profession or scope of practice.

1. “Clinicians should assess the patient using history and physical examination to exclude identifiable causes of facial paresis or paralysis in patients presenting with acute onset unilateral facial paresis or paralysis”

A thorough history is important regardless of the ailment. When paralysis is the end result, a thorough differential needs to happen in order to rule out other factors that could affect the facial nerve.

For instance, using the objective portion of the examination can help to rule out a stroke. The history can help to rule in cancer.

As a PT, ensure that you are taking a good history and physical exam in order to ensure that nothing is being missed.

2. “Clinicians should not obtain routine laboratory testing in patients with new onset Bell’s palsy”

“Risk: Missing a potential cause of Lyme disease, which is considered based on a thorough history.

Benefit: avoiding unnecessary testing and treatment, false positives and cost savings”

This is outside of the scope of PT and I will defer.

3. “Clinicians should not routinely perform diagnostic imaging for patients with new onset Bell’s palsy.”

“Benefit: avoidance of unnecessary radiation exposure, incidental findings, contrast reactions and cost savings”

“Risk: missing other causes of facial paresis”

“Opportunity for patient education”

4. “Clinicians should prescribe oral steroids within 72 hours of symptom onset for Bell’s palsy patients 16 years and older”

“Benefit: improvement in facial nerve recovery, faster recovery”

“Risk: steroid side effects and cost of therapy

Exceptions: diabetes, morbid obesity, previous steroid intolerance and psychiatric disorders.”

5. “clinicians should not prescribe oral antiviral therapy alone for patients with new onset Bell’s palsy”

“Benefits: avoidance of medication side effect, cost savings”

Risks: none

6. “clinicians may offer oral antiviral therapy in addition to oral steroids within 72 hours of symptom onset for patients with Bell’s palsy”

Benefit: small potential improvement in facial nerve function

Risks: treatment side effects, cost of treatment

Patient preference: “significant role for shared decision making”

Exceptions: same for corticosteroid use

6. “clinicians should implement eye protection for Bell’s palsy patients with impaired eye closure”

Eye protection is standard of care.

Risks: costs of eye protection implementation, potential side effects of medication.”

This falls into the plan of care for PTs. Sometimes the amount of time that the patient has with a physician is less than 10 minutes. (I’ve read that an average patient physician visit is 11 minutes).

Because of this, the patient may not fully understand what to do once diagnosed with Bell’s palsy, and this can be within the role of the PT.

7. “Clinicians should not perform electrodiagnostic testing in Bell’s palsy patients with incomplete facial paralysis”

8. “Clinicians may offer electrodiagnostic testing to Bell’s palsy patients with complete facial paralysis”

Benefit: provide prognostic information for the clinician and patient, identification of potential surgical candidate

Risks: patient discomfort and cost of testing

8. “no recommendation can be made regarding surgical decompression for Bell’s palsy patients”

“Concerned about the facial deformity may make it some patients willing to pursue a major operation for a small increase in the chance of complete recovery while others may be more willing to except the chance of poor outcome to avoid surgery”

“The group was divided as to whether the evidence supported no recommendation, or an option for surgery. This difference of opinion derived from controversy regarding the strength of evidence”

9. “No recommendation can be made regarding the effect of acupuncture in Bell’s palsy patients”

“The GDG was divided regarding whether to recommend against acupuncture, or to make no recommendation.”

10. “no recommendation can be made regarding the effect of physical therapy in Bell’s palsy patients”

There are conflicting statements regarding varying clinical practice guidelines.

I have only had one patient with Bell’s palsy that demonstrated significant improvement greater than 90 days since the diagnosis. Is it possible that time had a strong let effect than PT…sure…it’s possible.

Typically, the recovery would’ve taken place by three months, but the patient made progress while in therapy.

Don’t get me wrong, I don’t think that PT is the end all be all for many diagnoses or patients, but I do believe that the interventions had an effect on this particular case.

There may be some patients that could benefit from therapy. In saying this, my experience would tell me that it is a small percentage of patients.

“patient may benefit psychologically from engaging in physical therapy exercises”

11. “clinicians should reassess or refer to a facial nerve specialist those Bell’s palsy patients with 1. New or worsening neurologic findings at any point, 2. Ocular symptoms developing at any point, or 3. Incomplete facial recovery three months after initial symptom onset”

“Identifying alternate diagnoses in the absence of recovery, and potential assessment for rehabilitative options…However based on the natural history of Bell’s palsy, the majority of patients will show complete recovery three months after onset.”



Click to find the Article.

Cervical myelopathy: how to test clinically

“… The onset is often insidious with long periods of episodic, stepwise progression, and may present with a vast array of clinical findings from patient to patient.”

Cervical myelopathy is like neck pain to the extreme. It isn’t just a neck issue, but it ends up encompassing anything below the neck. It can cause arm symptoms, leg symptoms, difficulty walking, weakness throughout the body, spastic robot-like walking, and breathing issues.

This is a neck problem that needs to be addressed ASAP!

Let’s take a look at some of the research on this problem, what your therapist should check, and when it’s time for the patient to be sent back to a physician for imaging to determine if the patient is a candidate for surgery…it is that important.

Some quick stories (or not so quick).

I’ve had two patients with cervical myelopathy. One patient had symptoms of this, but also had arm problems from a previous injury. Because of this, the CSM (cervical spine myelopathy) was delayed in diagnosis until the patient demonstrated abnormal gait…10 months later!

The second case was picked up in the clinic immediately on the first day. I performed this cluster, to be learned later, on the patient and he was very positive. We had a conversation about the need for imaging and a consult with a neurosurgeon. The patient essentially said…thanks but no thanks.

Unfortunately this patient lost use of his hands and developed a walking pattern that was very abnormal before he decided that surgery was the right choice.

Here’s a quick Video describing CSM.

“May involve lower extremities first, weakness of the legs, and spasticity”

Spasticity is an issue that could be seen in walking for some people, but is testing using movements under speed like in this Video

What we will see is that the body reflexively slows down or stops the movement from happening rapidly.

“lower motor neuron findings in the upper extremities such as loss of strength, atrophy, and difficulty in fine finger movements, may present”

This means that we may see generalized weakness, loss of muscle mass (smaller muscles) and difficulty with picking up pennies and buttoning buttons.

“neck stiffness, shoulder pain, paresthesias in one or both arms or hands, or radiculopathic signs”

Neck stiffness is self explanatory. The neck movement may not be fluid or it may be restricted due to pain. There may be symptoms such as pain, tingling or numbness radiating into the shoulder(s) regions, arm(s) region or down to the hand(s) region. We may also see changes in sensation or reflexes.

“An MRI is most useful because the tool expresses the amount of compression placed on the spinal cord, and demonstrates relatively high levels of sensitivity and specificity.”

There is little reason for a PT to recommend an MRI, unless there are specific conditions found during the evaluation. The type of presentation notes above is one reason for a PT to recommend an MRI to the referring physician or the patient’s primary care physician.

X-rays do not do a good job of demonstrating any soft tissue (muscle/spinal cord/disc/ligaments/tendons) abnormalities.

Mind you, this presentation is not common and for the most part, an early MRI is not indicated for neck or back pain.

“The tests, when used alone, are not overtly diagnostic and may lead to a number of false negatives and in rare occasions, false positives”

It is recommended that, when CSM is suspected, the physical therapist use the cluster (groups) of testing in order to strengthen the likelihood of this suspicion. One test used alone is not enough to consider other testing.

“in reality, the diagnosis of CSM involves MRI findings and clinical findings, with equal weighting of both results”

Because the clinical exam is so important for this diagnosis and subsequent imaging, it is important that the PT and physician be familiar with the testing described.

“Of the 10 variables included in the regression modeling, the tests of Babinski and Hoffman’s signs, the Inverted Supinator sign, gait Abnormality, and age > 45 years were retained.”

I’ll be honest. In my first 10 years, I never tested for the inverted supinate sign or Hoffman’s sign until I read this paper. This is a testimony to continuing one’s education beyond taking courses. I don’t recall (those that know me know that I have a pretty good memory) ever learning this cluster through any of the coursework that I took since 2007.

After reading this article, I practiced these tests on a bunch of healthy individuals, those with neck pain in which I didn’t suspect a spinal cord issue, so that I could get better st the test and understand the normal response. This way, I learned the test mechanics and felt confident performing the test on anyone. It enabled me to understand the difference between the “healthy” patients on which I tested this specific cluster and the few in which had a positive test.

Rant: I hear it from so many students and new grads that they feel like they haven’t learned how to perform the tests or what to see as a result of the test because they only get to test healthy individuals. Having gone through the mechanics of this cluster for years, I hope that students understand that they must become confident at performing the mechanics of the test (kinesthetic learning) and know how a healthy response looks. One may go his/her entire career without ever seeing this presentation, but that doesn’t mean that one can’t perform the test and understand a normal result. I bring this up because I hear the same type of arguments regarding vestibular testing and ocular testing.

Every patient that has a history of stroke gets a vestibular-ocular exam because there may be lingering positive testing after the neurological event. This again strengthens my ability to perform the test and increases my likelihood that I will see positive testing…so I know what it looks like for future patient evaluations that may come in off of the street through direct access.

“A finding that included three of five positive tests yielded a positive likelihood ratio of 30.9 and a post test probability of 94%”

Even if you’re not a statistician, this is important information.

A positive likelihood ratio greater than 10 is an indication that your testing is giving a result that increases the chances of that being the diagnosis.

A post-test probability of 94% indicates that there is less than a 10% chance that the diagnosis or classification is incorrect after testing.

This is a much better percentage than we have of most orthopedic issues.

“”this study found that selected combinations of clinical findings that consisted of (1) gait deviation; (2) + Hoffman’s sign; (3) inverted supinator sign; (4) + Babinski test and (5) age > 45 years were affective in ruling out and ruling in cervical spine myelopathy.”

If you are a student and plan on treating patients…you must know these tests.

If you are a therapist treating these patients…you must know, be confident administering and understand the repercussions of a positive test.

If you are a patient…know that not all therapists have the same training and some may not even know these tests exist. I hope this makes you take a more thoughtful approach in choosing your next PT.

Article

Medicare for all

Are you paying attention?

Medicare for all would not be a great option, since we can barely sustain Medicare for some.

Government has to get more and more creative in order to make the 💰 last longer.

Part of that creativity is to reduce output.

Another part of that will be to increase revenue to this system.

Reducing output is easy. They are simply paying less for services and taking less risk than previous years.

For instance, ACO (hospitals and other entities) are seeing less reimbursement than previous years for the same procedure.

Less income means that the hospitals have to find other ways to generate income or to become “leaner” in their operations. This may mean less one-one time for PTs.

What do you think the solution should be?

See some of the comments to understand why we are running into problems.

Functional movement screening: the use

“The rehabilitation professional must realize that in order to prepare individuals for a wide variety of activities, screening of fundamental movements is imperative.”

I agree with this statement. I disagree that we yet have a tool that can screen all individuals from all sports. This screening tool has yet to prove its worthiness of use on athletes.

I recently was certified by USAW as a weightlifting coach. I really like what they use to screen participants before allowing them to train the weightlifting lifts of the clean and jerk and snatch. They use the basic movement patterns, without load or speed, that are needed in order to perform the entire lift safely.

This makes logical sense, but I don’t think a study has been performed to see if this is a good/bad thing to do prior to allow safe lifting.

The FMS is proposed to be a screening tool for athletes and tactical workers. I’m not sure this one tool can encompass all of the movements required in life.

It’s still a good thing to learn about, not for use as a screen, but instead to better understand how the body as a system can move through the spectrum of very stiff and weak through very mobile and supportive.

“Many individuals train around a pre-existing problem or simply do not train their weaknesses during strength and conditioning (fitness) programs.”

If a person is unaware of a problem, this is also a problem. I would be all for a low cost screening tool, which everyone is required to have tested on a yearly/decade basis.

For instance, someone that lacks ankle mobility may not know that they are unable to squat without something under their heels. They may not know that this leads to increased use of the anterior chain, which increases knee stresses. They may not utilize their hips and may round their back when performing their repetitive squatting activities.

There are so many possibilities for a person to lose mobility, that this should be screened. The problem is that we have yet to know an effective screening tool.

“The perception of many past researchers is that no set standards exist for determining who is physically prepared to participate in activities”

If there are no standards, then everyone can participate in a physical training program. This is only partially true. There are some standards, but not many.

1. The person must be breathing

2. The person must not be at a major risk of death if participating in an exercise program

3. Start exercising!

“…the main goals in performing pre-participation, performance, or return to sport screening are to decrease the potential for injury, prevent re-injury, enhance performance, and ultimately improve quality of life”

This is what makes a universal screening tool so hard to find. I don’t even think we have a tool for different positions of the SAME sport because the requirements are so diverse. I keep bringing up the USAW screening tool, but that’s because the athlete, in the end only needs to be safe enough to perform TWO movements. The screening tool has more movements than needs to be performed. If this were to hold true for any other sport, the screening tool would be too long to be useful.

“…intended purpose of movement screening (1) identify individuals at risk, who are attempting to maintain or increase activity level (2) assisting in program design by systematically using corrective exercise to normalize or improve fundamental movement patterns (3) providing a systematic tool to monitor progress and movement pattern development…(4) creating a functional movement baseline”

I can agree with all of the above stated. Im not sure if research supports these statements, but they sound pretty good.

I do like the idea of creating a movement baseline, but that baseline measurement will need to be extensive enough to capture relevant information to that patient.

“The FMS (TM) is comprised of seven fundamental movement patterns (tests) that require a balance of mobility and stability (including neuromuscular/motor control)”

This is true. The seven movement patterns tested are adequate tests for ADL’s but I don’t know if it goes far enough to test anything other than a persons baseline movement.

“The term ‘regional interdependence’ is used to describe the relationship between regions of the body and how dysfunction in one region may contribute to dysfunction in another region”

I speak with many PTs throughout the week that know this term and can recall this term, but don’t apply this term on a daily basis when working with people. For example, a significant loss of dorsiflexion (ankle flexibility) will keep the knee from bending and shifting towards your toes. This will in turn cause you to learn more forward with your hips.

A loss of movement at your shoulder can make you move your back more when reaching overhead.

This is the term regional interdependence at play.

“Programmed altered movement patterns have the potential to lead to further mobility and stability imbalances, which have previously been identified as risk factors for injury”

This is where I start to deviate a little from the article. There are way too many logical jumps being made without proof that a screening tool is predictive of injury.

“…an important factor in prevention of injuries and improving performance is to quickly identify deficits in symmetry, mobility, and stability because of their influences on creating altered motor programs throughout the kinetic chain”

I don’t agree with this.

Everything here forward is my opinion and I don’t have any proof that it’s true: we live in an asymmetrical world. We start off as one handed or one footed. We play sports that drive this asymmetry. It’s hard to say that moving towards a more symmetrical society will improve performance in asymmetrical sports or activities.

I personally don’t think it happens.

There are many saying that at a young age that kids shouldn’t specialize, and I would agree with that, but at what age does specialization become more appropriate. I remember hearing stories about Ken Griffey Jr (one of the greatest baseball players of all time with baseball being a very asymmetrical sport) playing basketball in order to improve mobility and hand eye coordination.

It’s a theory that working towards symmetry improves performance, in just not at that point yet.

“Scores serve to tell the professional when a person needs more investigation or assessment”

The score on the movement screen does not predict injury. It just states that the person doesn’t move like the ideal.

For instance, my shoulder mobility for the internal/external rotation test is not ideal. That’s expected for me because I have shorter arms and am overweight. The investigation of this test is that I have to lose weight in order to see if that has an effect on my testing. The same “problem” of being overweight can affect the rotary test in quadruped as the belly can get in the way of the test. “Problem” solved. It may not be a muscle/joint problem at all.

Read the article to see the testing and what the authors propose that the test is measuring.

Link to article

PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”

SOAPBOX: ADEQUATELY SUPERVISED DOES NOT MEAN THREE TIMES PER WEEK FOR SIX TO EIGHT WEEKS. THE PATIENT SHOULD BE PERFORMING THE HOME PROGRAM AND THE THERAPIST IS IDEALLY ONLY A PHONE CALL AWAY. THE PATIENT SHOULD RETURN IF SOMETHING U EXPECTED HAS OCCURRED OR THE PATIENT NO LONGER IS ABLE TO REPRODUCE THE SYMPTOMS WITH THE LOAD THEY ARE USING AT HOME.

“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

Reflections from “The Alchemist” Part II

“Everyone seems to have a clear idea of how other people should lead their lives, but none about his or her own.”

Are you happy?

Do you love your profession?

Are you satisfied with the time you spend with your family?

Matthew 7:5

You hypocrite, first take the log out of your own eye, and then you will see clearly to take the speck out of your brother’s eye.

This is the first passage that comes to mind when I think of the above quote.

I’ve met many people in my life say I should’ve been a lawyer, I should’ve gone to medical school, I should’ve done this or that. A wise dumpster diver, turned scholar, turned flight attendant by the name of John Patrick Luby III used to say “Never should (shit) on yourself!”

All that really matters is that I’m happy in life and content with where I’m at as a professional. When I introduce myself and people say what do you do you I said I do physical therapy. I rarely say that I’m a physical therapist.

As much as I do for the profession and within the profession, I never want the profession to define me. I am a father. I am a husband. I am a son. I am my own person.

Lately, I have been spending time counseling others on clear pass. I try my best to stay unbiased and to not give my opinion as much as I try to receive answers and ask questions to those that are looking for their careers. I do my best to give an objective opinion regarding finances, regarding passions, regarding job stability, job, but most importantly happiness.

It’s not my job, nor my want, to try to push someone into a direction. I personally feel it’s my responsibility to help those that are seeking assistance in finding their own career path I never do this by pushing them in a direction, but instead help them to see where their passions may lie.

I’ve met many people that are dissatisfied with how their life is playing out, but what they fail to see is that it’s now until they’re no longer living, they are free to make choices to affect the outcome going to change their future is the president. Their past Cano want to change it, but the choices they make today will affect the outcome as of tonight and tomorrow. I making different choices they can choose to take a different path in life, but many have difficulties making those decisions. There are outside forces that may hold people in certain positions in life, such as golden handcuffs, family responsibilities, stature and such.

Ultimately, it is not my job to direct others, not other’s job to direct me.

Reflections from “The Alchemist” Part I

“That was what made traveling appeal to him that he always made new friends, and he didn’t need to spend all of his time with them. When someone sees the same people every day, as had happened with him at the seminary, they wind up becoming part of that person’s life. And then they want the person to change.”

This is a very pessimistic view of society. At one time I used to believe this is true. But when you love someone, you love someone for the reasons that they are that person. Should you change that person, you may not love that person again.

I think it’s a very dangerous path way to try to change someone into something that you believe to be a better person, when you truly love that person as they are. I think there is a difference between trying to help someone become a better version of themselves, versus trying to help someone become the better version YOU believe they should be for YOUR own sake.

Good or bad, I believe that I was parented very well. My dad could give two shits about what I do for a living. All that mattered to him was that I was happy. When I told him that I was going to college, he didn’t care as long as that’s what I wanted to do. Because when that’s the case, that’s what he wanted me to do. When I quit jobs and started new ones, he didn’t care as long as I was happy. When I got married, and then divorced, he only cared that I was doing what I thought was right for me. That’s love. That’s not trying to change someone.

My mom is the opposite. She will try to interject herself into what she feels is best for me because she wants me to be happy and believes that by interjecting herself that it will hall me become happy.

I have always been my own person, so I usually brush off anyone or thing that starts to take control away from my decisions…u less it is something that is prioritized over the decisions that I make.

For instance, I had a good job, not a job I loved because it wasn’t challenging for me, but a good job. Great pay, great benefits, tons of vacation time, but I wanted more. My family is a priority, but so is happiness. I wouldn’t have been happy had I stated because it became the same thing day in and day out. I needed to change.

I made that change and it was a poor decision in hindsight. The change was right, but the way it happened and the preparedness that I had for the cha he was poor. I don’t regret making the decision, even though my wife cautioned me at the time, because I would’ve been in a great job for the wrong reasons.

I am really happy now.

It’s easy to not to want to change someone when there is nothing but love for that someone. Once there is anything other than love for the person in front of you, the thoughts of “I wish you would…” start to rise in your head. These thoughts can become powerful and take the place of the love that was once there. Unchallenged, resent sets in and love is but memory.

All I want is for people to be happy. It’s a byproduct of my parenting and my experiences.

These passages can be found in this book, which I highly recommend.

“That was what made traveling appeal to him that he always made new friends, and he didn’t need to spend all of his time with them. When someone sees the same people every day, as had happened with him at the seminary, they wind up becoming part of that person’s life. And then they want the person to change.”

This is a very pessimistic view of society. At one time I used to believe this is true. But when you love someone, you love someone for the reasons that they are that person. Should you change that person, you may not love that person again.

I think it’s a very dangerous path way to try to change someone into something that you believe to be a better person, when you truly love that person as they are. I think there is a difference between trying to help someone become a better version of themselves, versus trying to help someone become the better version YOU believe they should be for YOUR own sake.

Good or bad, I believe that I was parented very well. My dad could give two shits about what I do for a living. All that mattered to him was that I was happy. When I told him that I was going to college, he didn’t care as long as that’s what I wanted to do. Because when that’s the case, that’s what he wanted me to do. When I quit jobs and started new ones, he didn’t care as long as I was happy. When I got married, and then divorced, he only cared that I was doing what I thought was right for me. That’s love. That’s not trying to change someone.

My mom is the opposite. She will try to interject herself into what she feels is best for me because she wants me to be happy and believes that by interjecting herself that it will hall me become happy.

I have always been my own person, so I usually brush off anyone or thing that starts to take control away from my decisions…u less it is something that is prioritized over the decisions that I make.

For instance, I had a good job, not a job I loved because it wasn’t challenging for me, but a good job. Great pay, great benefits, tons of vacation time, but I wanted more. My family is a priority, but so is happiness. I wouldn’t have been happy had I stated because it became the same thing day in and day out. I needed to change.

I made that change and it was a poor decision in hindsight. The change was right, but the way it happened and the preparedness that I had for the cha he was poor. I don’t regret making the decision, even though my wife cautioned me at the time, because I would’ve been in a great job for the wrong reasons.

I am really happy now.

It’s easy to not to want to change someone when there is nothing but love for that someone. Once there is anything other than love for the person in front of you, the thoughts of “I wish you would…” start to rise in your head. These thoughts can become powerful and take the place of the love that was once there. Unchallenged, resent sets in and love is but memory.

All I want is for people to be happy. It’s a byproduct of my parenting and my experiences.

Link to book

Vince Gutierrez, PT, DPT, cert.MDT
Movementthinker.org
815-210-4869