Advertisements

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

Advertisements

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 đź’° 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.

Patients with Medicare using PT

“Services were required because the individual needed therapy services”

For a person to need therapy services, they must have a plan of care certified as necessary by a physician or other referring professional.

“A plan for furnishing such services has been established by a physician/NPP or by a therapist providing such services and is Eperiodically reviewed by a physician/NPP”

A PT is allowed to establish a plan of care for patients, but the insurance doesn’t necessarily have to pay for it. In order for Medicare to pay for a plan of care that is established by a physical therapist, a physician or other referring provider must sign off on that plan of care.

“Services are or were furnished while the individual is or was under the care of a physician…In certifying an outpatient plan of care for therapy a physician/NPP is certifying that the above conditions are met. Certification is required for coverage and payment of a therapy claim.”

If a physician/NPP provides a referral at the time of evaluation, this ensures that the patient was under the care of a referral source at the time of the evaluation. This becomes important because there are patients that will wait to start therapy for months or years after a referral was issued. There is not guarantee that the referral source will certify the POC at this later date. If this POC is not certified, then the treatment will not be covered by Medicare.

“Claims submitted for outpatient PT, OT, and SLP services must contain the National Provider (NPI) of the certifying physician identified for a PT, OT, and SLP plan of care”

Although this is a technicality, this may cause a denial of payment if the NPI number, of the referring professional, is not included on claims.

“Although there is no Medicare requirement for an order, when documented in the medical record, an order provided evidence that the patient both needs therapy services and is under the care of a physician. The certification requirements are met when the physician certifies the plan of care”

Again, this needs to be reiterated over and and over, the patient needs to be under the care of a physician when in physical therapy. The referral can serve to show that the patient was under the care of a physician at the time of the initial evaluation. In the end, the only thing that matters is that the physician/NPP signs off on the plan of care established by the PT.

“Payment is dependent on the certification of the plan of care rather than the order, but the use of an order is prudent to determine that a physician is involved in care and available to certify the plan”

Have you had enough of this yet.

Do you think that there is a reason this is spelled out so frequently in the documentation?

Some don’t follow the rules of the game.

“The services must relate relate directly and specifically to a written treatment plan as described…must be established before treatment is begun…written or dictated.”

We all know that a plan is required.

Some don’t know how to write frequency and duration.

Some don’t know how to write interventions, or some perform interventions not written.

They must be written and signed off on in order to perform.

“The signature and professional identity of the person who established the plan, and date it was established must be recorded with the plan”

No brainer…or is it?

Stamped signatures are not signatures according to CMS, and stamps are not approved.

“Outpatient therapy services shall be furnished under a plan established by:

A physician/NPP

The physical therapist who will provide the physical therapy services”

This is critical. A therapist doesn’t need to have a POC signed if the physician/NPP creates the plan and it is abided by the PT verbatim.

Also, the PT doesn’t need to be licensed if practicing under a physician.

“The plan may be entered into the patient’s therapy record either by the person who established the plan or by the provider’s or supplier’s staff when they make a written record of that person’s oral orders before treatment is begun.”

This is a formality, but it has to do with dictating a note. Treatment can not be started by anyone other than the PT or immediately supervised by the PT that created the plan, before it is entered into record.

“The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits.”

I tend to do one billable unit on the days of an evaluation. This is based on how much time you spend with the patient covering an intervention, or if an untamed intervention is performed.

“Therapy may be initiated by qualified professionals or qualified personnel based on a dictated plan. Treatment may begin before the plan is committed to writing only if the treatment is performed or supervised by the same clinician who established the plan”

This means that the PT or PTA can start treatment on the initial visit. The PT must be in the office supervising the PTA at this point.

Some people, like Anthony Maritato, use this method to establish a relationship between the treating therapist and the patient.

Others, like Rick Gawenda, find this to be a less efficient use of time.

“It is acceptable to treat under two separate plans of care when different physicians/NPP refer a patient for different conditions. It is also acceptable to combine the plans of care into one plan covering both conditions if one or the other referring physician/NPP is willing to certify the plan for both conditions”

I’ve seen some clinic totally prefer to treat the patient 2x/week for one ailment and 2x/week for another ailment.

Take a guess why…it sure ain’t for the patient’s benefit.

Medicare limits how many units can be charged in a session (essentially how much money can be paid in a session). If there is a way around this, you can bet that money hungry clinics will find this workaround.

“The plan of care shall contain, at minimum, the following information as required by regulation:

Diagnosis

Long term goals

Type amount and frequency of therapy services”

The evaluation doesn’t need much. It would be great if it established medical necessity, but is it required…NOPE!

The diagnosis can either be ICD codes or the written diagnosis since it is not spelled out.

“Long term treatment goals should be developed for the entire episode of care in the current setting”

This is something new to many therapists. Medicare doesn’t specifically require short term goals. If they are not required, do they need to be done? In school it is taught to set short term goals as a step towards the long term goal. In reality, every minute counts. The time spent creating and typing short term goals could be used elsewhere. Creating short term goals is literally robbing Peter to pay Paul, but Paul doesn’t need the money.

“…long term goals may be specific to the part of the episode that is being certified. Goals should be measurable and pertain to identified functional impairments”

Goals should be measurable and timely. They should relate to function. There is a lot of grey area in this portion. Subjective measurements are not the most reliable and maybe shouldn’t be used in goal writing.

I see frequently “to increase hip abduction strength to 4/5”

This goal is measurable, albeit loosely and has no tie to function.

I personally like to use outcome measures and specific functional testing in my goal writing. For instance, the patient will improve the (TUG, Tinetti, Berg, chair rise, single leg stance, lower/upper extremity functional scale, yellow flag risk form) in order to …

“…documentation should state the clinical reasons progress cannot be shown”

This is built into many EMRs now.

Sometimes I will write that the symptoms are not reducible through movement or modulation. Other times, I will write that the patient is not consistent with the HEP. Sometimes, it’s that it is a maintenance case and the patient is unsafe to perform exercises with an untrained professional due to fall risk, BP fluctuations or rapidly changing SpO2.

This is where it really pays off to have read some of the textbooks that were recommended in PT school. I particularly recommend the ACSM handbook.

“The amount of treatment refers to the number of times in a day the type of treatment will be provide…one treatment session a day is assumed”

In an outpatient setting, this is typically one. In an acute or subacute setting it may be BID (twice in a day) or even TID (thrice in a day).

“The frequency refers to the number of times in a week the type of treatment is provided”

I struggle with this one. Many therapists are putting 3 times per week for 4 weeks on all their plans. This isn’t being done because they believe it’s what is best for the patient, but because there is a corporate policy to get as many visits in per week as able.

I get frustrated with this type of plan. If you are a therapist and working in this setting, but only putting this plan down to keep from rocking the boat…you are abusing Medicare and should call CMS to report this activity.

Please and thank you.

“The duration is the number of weeks, or the number of treatment sessions, for THIS plan of care.”

This question is asked frequently. I will typically put down the number of weeks if I know that the surgeon only wants so many weeks of PT per a protocol. If it is not protocol based, the. I will typically put down the total number of visits expected for the episode.

Many of my patients (>80%) require an authorization and are typically given 12 visits to start. In this case, I will make the plan for 12 visits or 90 days, whichever comes sooner. I know that I have to do a progress note and get a recertification and ask for more visits at this time anyways.

“It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward and independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time.”

Again, I frequently get 12 visits to start. I try to make these visits as worthwhile for the patient as possible. For some cases I will see 3 times per week, but for many I will see 1 visit per week or 2 per 10 days. This way we are able to see the patient for the timeline of change that is expected. For instance, strength usually occurs in the first 6 weeks due to neuromuscular changes and hypertrophy happens after this timeframe. If we are seeing the patient for 12 visits in 4 weeks, then we may have exhausted the benefits before noting the change.

To me, that is a waste. Many patients agree with me on this because we make the POC together based on their finances (copays need to be paid each day regardless of how many times you are seen per week), work schedules and need/expectation to change over a given time period.

Again…PTs, if you don’t have this autonomy to create your own Plan of Care, are you truly an autonomous practitioner or are you simply a technician that is doing what a higher figure is telling you to do?

“When tapered frequency is planned, the exact Number of treatments per frequency level is not required to be projected in the plan, because the changes should be made based on assessment of daily progress”

This is one of the aspects that I take advantage of in the plan. At this point, I will write 12 visits over 12 weeks or 12 visits over 6 weeks. This way I may start at 3 visits and taper down to one visit per week.

“The clinician should consider any comorbidities, tissue healing, the ability of the patient and/or caregiver to do more independent self-management as treatment progresses, and any other factors related to frequency and duration of treatment”

I had a patient that hadn’t walked in years. The person had fluctuating blood pressures with activity and at times therapy was halted due to elevated BP. This patient was not safe to perform gait training independently due to fall risk and intermittent cardiac crises. This patient was treated 1-2 times per week with gait training and performed a Nu Step at home. The interventions that were skilled were performed in the clinic and the unskilled interventions were issued for HEP.

“…optional elements: short term goals, goals and duration for the current episode of care, specific treatment interventions, procedures, modalities or techniques and the amount of each.”

As much as this says “optional”, I’m not sure it is fully optional. For instance, this report notes that a therapist did not have the type of intervention in his POC as one of many reasons for repayment.

“Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient’s disease or condition or adjustments to the plan due to the lack of expected response unchanged. Only when the patient’s condition changes significantly, making revision of term goals necessary, is a physician/NPP’s signature required on the change.”

For me personally, when there is a major change in status that requires a change in goals and expectations, I phone the physician and alert the medical team to the change in status. I feel that it is important to relay this information to the physician personally, in addition to writing a progress note or re-evaluation.

“Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care… The date of the certification is signed is important to determine if it is timely or delayed”

This small detail is important. Although the physician may sign it, it also must be dated. I’ve had to send many evaluations back for a date.

“The physician/NPP’s certification of the plan satisfies all of the certification requirements noted above in (section) 220.1 for the duration of the plan of care, or 90 calendar days from the date of the initial evaluation, whichever is less.”

This is where things get confusing. If you set your plan for 90 days, then everything is good and no confusion.

If you set your plan for 6 weeks, then you would need to get another certification past 6 weeks.

I’ve seen some therapists just write the plan for 90 days on each evaluation in order to check the 90 day box. Don’t be that person. Put thought into your plan and don’t just set up your plan for 90 days because it’s the maximal allowable in one episode.

My duration varies from 4 weeks for acute back pain, 6 weeks for vestibular dizziness up to 12 weeks for neurological disorders. The only downside of doing this is that there is paperwork more frequently. The upside is that it forces a reassessment, which indicates whether or not a patient is responding to care.

“…the physician/NPP shall certify the initial plan as soon as it is obtained, or within 30 days of the initial therapy treatment.”

At my clinic, we have a spreadsheet that has the evaluation name, date and signature (yes/no). Once the signature is obtained, the name is removed from the spreadsheet.

Also, when discharging a chart we have a checklist of items that are expected to be in the chart. The signed evaluation is one of these items on the checklist.

“Evidence of diligence in providing the plan to the physician may be considered by the Medicare contractor during review in the event of a delayed certification”

Again, this is more of a standard operating procedure. When a note is faxed to a physician, the fax cover letter becomes a part of the record. This is done to demonstrate that due diligence was performed in attempting to get a note signed.

“Payment and coverage conditions require that the plan must be reviewed, as often as necessary but at least whenever it is certified or re-certified to complete the certification requirements. It is not required that the same physician/NPP who participated initially in recommending and planning the patient care certify and/or re-certify the plans”

This is also an opportunity for PTs. If a patient has a better relationship with the PCP compared to the orthopedic surgeon, it may be prudent to have the patient get the PCP to sign off on the recertification.

“If the physician wishes to restrict the patient’s treatment beyond a certain date when a visit is required, the physician should certify a plan only until the date of the visit.”

The evaluation template that we use from Theraoffice provides an area for the physician to change the plan if deemed appropriate.

“Certifications and recertification’s by Doctors of podiatric medicine must be consistent with the scope of the professional services provided by a doctor of podiatric medicine as authorized by applicable state law… Chiropractors may not certify or recertify plans of care for therapy services.”

This is huge. For instance, a podiatrist physician is only allowed to write a referral for their scope of practice. Seeing a patient from a podiatrist for an ailment that is outside of the scope of practice may result in a sticky situation, like Seinfeld encountered.

Also, Chiropractic physicians are not allowed to certify plans of care for PT. This applies to Medicare. You must be aware of the patient’s insurance in order to determine if other insurances have the same regulations.

“… The provider is precluded from charging the beneficiary for services denied as a result of missing certification”

This means that the provider or company that the provider work for will hound the physician’s office to get the evaluation or progress report signed. Otherwise, the amount paid was not approved to be performed.

The clinics are not allowed to charge the patient due to a lack of certification.

This is not meant to be legal advice, as this is my take on the Important passages from This manual regarding our profession.

If in need of more information on Medicare compliance, check out Nancy Beckley or Rick Gawenda

Second opinion

How many people will choose to get a second opinion before going in for a major surgery?

I would hope đź’Ż%!

I had an awesome conversation about 10 years ago when I was visiting Canada. There was a guy that traveled to Canada in order to get an opinion regarding back surgery. He was from San Diego. That’s a pretty far trip to see if he needs back surgery.

I asked him why travel that far for an opinion and he said that he wanted to reduce any bias on the doctor’s part regarding whether he was a candidate. For instance, the doctor in Canada would not be performing the surgery and it was unlikely that the doctor giving the opinion would be able to benefit from recommending surgery, since the patient would have surgery in California.

He avoided going for the opinion in California because the hospital system would profit from the surgery. The surgeon may have an arrangement with the hospital to ensure that the hospital gets a percentage of the money. We know that the hospital will make money during a surgery. Many people stand to profit from a surgery and the patient would do well to get an opinion from someone that doesn’t stand to benefit.

This brings me to my rant for now. 👇

Why don’t patients get a second opinion regarding physical therapy?

1. It’s not a huge expense

Physical therapy, on average will cost the insurance company about $1200 per episode of care. If the patient is paying 20% for the coinsurance, then it will only cost the patient $240/episode. This works out to about $50/week.

That’s relatively inexpensive compared to a large surgery. The question is: why not spend an extra $25 to see if a second therapist agrees with the first? If there is a disagreement in how treatment should be performed, then the cost may not be the chief factor.

This leads us to 👇

2. All therapists do the same thing

Not all PTs are trained the same! Don’t let a non-PT (such as surgeon or family doctor) tell you that it’s all alike.

Not all surgeons have the same reputation and skills. Not all PTs have the same reputation and skills. The only way that you, as a patient, will know about other’s skills and reputation is to ask and try.

If you are absolutely in love with your PT or MD, then so be it. Sing from the rooftops so that the reputation gets built. If you’re not…try someone different.

Sometimes the grass IS greener.

3. Convenience

I get it. A drive around the corner is much easier than a drive for an hour. It makes sense.

If we believe that not all therapists have the same training or passion for treating a specific issue, then we must also believe that these therapists are worth the drive.

Follow this example:

1. Patient A decided to go to a therapist close to home or work (we know that regarding gyms most people won’t drive more than 15 minutes from work/home). The therapy session costs the patient $240 out of pocket and the insurance pays $1000.

Let’s also say that the patient is being seen for low back pain or sciatica, since this is the number one reason to seek PT. The patient is seen in a clinic in which the therapist is there to punch a clock and see as many patients as possible because that’s how đź’° is made.

The patient doesn’t get much better and then returns to the doctor for a series of shots (more money and time). The shots are a 50/50 chance of working.

Half of the patients will then still have pain and now be shuffled to the next step, either pain management or surgical consult.

2. Patient B spent a little time to search for the therapist in a 20 mile area that best treats low back pain or sciatica. The patient makes an extra 20 minute drive. The therapist decides that the patient would ben for from 8 visits of PT over 6 weeks and the patient gets better because the therapist enjoys the job and works well with patients having this diagnosis.

The patient made a little more of an effort up front, but saved 💵 and ⏳ by choosing the right therapist instead of moving further along in the medical system.

Want a second opinion, send me a message.

PTA’s in an outpatient setting continued

“Low back pain syndromes (LBPS) affect more than 65 million Americans…For approximately 16 million people (8%), back pain is persistent or chronic…”

If you have a little bit of free time, you can read about back pain here.

“…a quarter of all referrals for outpatient physical therapy and one-half of all outpatient physical therapy visits are related to patients with LBPS.”

Hey New Grad ✊ are you 👂?

If you want to get really good at something and ensure job stability, then you should learn as much as you can about back pain.

If one out of every two visits per day is related to back pain, we should all be very comfortable with this diagnosis.

In my first job, I’d say that I had 2,500 visits per year with about 95% of those pertaining to the spine.

“Resnik et al reported that patients who spent more than half of their treatment episode of care with a physical therapist assistant reported worse functional outcomes and utilized more visits compared with patients with less physical therapist assistant involvement.”

Again, this is the second post in the series on PTA’s usage in the outpatient setting.  You can find the first post here.

“It is generally assumed that practitioners must possess many years of clinical experience to achieve the best results with patients and that years of experience are associated with better clinical outcomes.”

What?! I don’t agree with this.

Unfortunately, not all experience is good experience. I’ve read Tony Delitto state in an article that one year repeated twenty times is it ideal. I would much rather have a PT with two years of experience and two years worth of learning from mistakes.

“Almost half of the sample had chronic low back pain.”

This is in line with some of the statistics that I’ve heard stating that back pain makes up about 40% of all chronic pain.

“The top 3 diagnoses were pain (34.8%), sprain or strain (25.5%), and herniated disk (19.3).”

About 90-95% of all back pain is “non-specific”, meaning that we can’t attribute it to a specific tissue strain or sprain. Herniated did a are common in the population, but we can’t always attribute a herniated disc (HNP) as the cause of pain.

“On average, patients in the best clinic performance group improved 19.2 OHS points, while patients in the worst clinic performance group improved an average of 16.4 OHS points.”

This is great news!

This means that on average people get better. I used to work in a clinic in which the manager would try to schedule people with back pain as soon as possible. If we know that they will likely improve and they improve on our watch, then they are likely to use post hoc reasoning and attribute improvement to seeing the PT.

I used to joke with patients and say that they simply need to breathe the city air in the basement of the hospital in order to improve. Obviously, it’s a joke, but we have to tell patients that most injuries improve with time.

“Patients in the best clinic performance group utilized, on average, 7.7 (SD = 4.1) visits per treatment episode compared with 7.9 (SD = 4.1) in the middle clinic performance group and 9.3 (SD = 4.9) in the worst clinic performance group.”

This is where it gets interesting. There wasn’t a major difference in outcomes on the scoring improvement, but some clinics needed an extra 2 visits compared to other clinics, on average.

If an average PT sees 5 evaluations per week and it takes an extra 2 visits, then that ONE PT is averaging an extra 20 visits per month (assuming half of the evaluations are back pain). This means that the therapist keeping patients for more visits is making the clinic an extra $2,000 per month from taking longer to discharge patients.

“…clinics that were lower utilizers of physical therapist assistants were 6.6 times more likely to be classified into the high effectiveness group compared with the low effectiveness group, 6.7 times more likely to be classified into the low utilization group compared with the high utilized group, and 12.4 times more likely to be classified into the best performance group compared with the worst performance group.”

This is essentially stating that clinics that use PTAs with a lower frequency in outpatient tend to be better in terms of outcomes and faster to discharge. This mirrors the link to the study from above.

For me this is interesting because I would have never thought to ask the question in the first place. It’s good to see that someone is doing this research to help clinicians in their decisions to 1. Choose between PT and PTA school and 2. Utilize PTAs and how to best utilize PTAs in an outpatient setting.

“Our strongest finding was that clinics that had lower utilization of physical therapist assistants were much more likely to be in the “best” category of each type of group (i.e. highest effectiveness, lowest utilization, and overall performance).”

Link to article

Car 54

Do we see a problem with this picture?

How far do we have to go still in order to educate the public?

When people think back pain, they don’t think of physical therapists. When people think concussion, they don’t know where to turn.

As a professional, I do all that I can to educate the public, but in the end still have to apologize for our profession’s apathy.

We have no brand…better yet we have a brand, but not a consistent one.

I believe it was Therapy Insiders that did an episode of asking people on the street what they thought of when they heard the term physical therapy. Our roles in the SNF and acute care hospitals seem to be cemented in people’s mind because these answers were given, but we weren’t the first ones thought of for pain or back pain.

We have to do a better job folks. Get out there and educate the public on SoMe, in person, small groups or online. Every little bit helps. Let’s hope that if this same survey were done again in a year that the number would be far less.

Online presence

I think that this sums it up. If we aren’t posting online on our personal websites, on social media (SoMe) or on a work website then we are missing out on contact points with over a third of the population. Our role has to grow larger than treating the patient that walks in the door with a referral. We, as a profession, have to go out there and educate the public, medical doctors, podiatrists, dentists, laborers, plumbers, and at times other therapists.

We don’t get to sit in our offices anymore and wait for patients to come to us, but we have to go out and educate!

How are you establishing a presence in your community, your workplace and your profession?

Leave comments below.

Do you suffer from knee pain?

Do you “suffer” from knee pain?

“Within this new paradigm, overweight and obesity contribute to OA through biomechanical (increased joint load) and inflammatory mechanisms.”

​There is newer research that indicates body fat can release inflammation. Think about this, inflammation can cause pain and there has been the old wives tale that being overweight can be the cause of pain, but now there is research to back up the claim that excess body fat can be a factor in having increased pain.

“Years lived with disability due to high body mass index have also increased markedly for males and females aged 15-49 years since 1990, emphasizing the potential contribution of rising obesity levels to global OA (osteoarthritis) burden among younger people”

​Being obese takes a toll on health. This is not a surprise. The heavier a person is, the more energy and work required in order to just move. Pair this with increased pain sensation and movement may actually decrease over time.

“Research has shown that the greatest risk factor predicting the development of knee OA in young an middle-aged people is a previous traumatic knee injury”.

​If you injure your knee traumatically, the research covers ACL surgeries and meniscus surgeries, then there is a high likelihood of developing knee osteoarthritis.

“Radiographic findings are not well correlated with symptoms and are unlikely to alter the management plan or predict future disease progression”

​THIS MAY BE THE MOST IMPORTANT MESSAGE FOR PATIENTS TO UNDERSTAND. Just because an X-ray shows “degeneration”, “osteoarthritis”, “joint narrowing”, “bone spurs”…so on and so forth…doesn’t mean that this is causing pain. What we now is that these findings are common as we age. There’s an analogy that these findings are similar to wrinkles on the skin, they are just wrinkles on the inside. Not too many people worry about skin degeneration in the form of wrinkles. The same should hold true regarding some of the results of an X-ray or MRI.

“Overuse of MRI is costly for health systems and may lead to unwarranted surgical intervention.”

​The most important part of this is that MRI’s may lead to surgeries that aren’t needed. Let’s go back to the wrinkle analogy. Just because something doesn’t look young and supple…like it does in the textbooks, doesn’t mean that everyone should have a surgery to remove wrinkles. The same holds true for wrinkles on the inside.

“…comprehensive assessment of young patients should include 3 key components: 1. A patient-centered history; 2. Physical examination, including performance-based tests; and 3. Administration of appropriate patient-reported outcome measures (PROMs).”

​I challenge this sentence in that it is only limited to young patients. This 3 step process should be performed on every patient, REGARDLESS OF DIAGNOSIS! Every patient should be treated as an individual and not as a diagnosis. Everyone has a different story. Every patient has different needs. Every patient has different goals that are specific to that patient in front of you. The only way that this can be learned by the therapist is by performing a patient-specific evaluation.

​The only way that we know if a patient is actually improving, aside from simply asking them, is to perform tests and measures. When your internet isn’t going as fast as we think it should, we can always run an internet speed test. This is an unbiased way to test the thought that it is running slow. We need the same types of tests and measures in physical therapy. These should be performed by your PT within the first 2 visits.

​Finally, there is a patient reported outcome. This is a way for the patient to answer questions in order to determine if the patient actually believes that they are better or not. The questions have been validated by some research and the form should be universally known.

“…education about the neurophysiology of chronic pain and contribution of emotional and social factors to the pain experience may be relevant for some patients.”

​Many people still believe that an injury happens and therefore there must be pain. It doesn’t quite work this way. The brain can overcome any of those “inputs” that theoretically can cause pain. For instance, we’ve all heard the story of a person performing feats of strength like lifting a car off a child, but few people hear about the injuries that tend to happen after this feat of strength. The brain can overpower the body’s ability to feel pain. On the flip side, the brain can cause pain without injury. This is a little known fact by many PT’s unfortunately. This type of pain requires a completely different type of treatment than someone that is actively experiencing an injury. This is more complex than can be described in this article, but there will be future posts to describe this phenomenon.

“…exercise can reduce pain and improve physical function for knee and hip OA…Muscle strengthening can play a role in managing symptoms…Neuromuscular training programs can address sensorimotor deficits often associated with knee injury, including altered muscle activation patterns, proprioceptive impairment, functional instability, and impaired postural control”

​This is a mouthful. To summarize, there is rarely a reason not to “get stronger”. Being strong enables people to do more than being weak. Don’t get me wrong, there are multiple ways to get strong, but there are also multiple ways to get injured while getting strong. Please, if you have little/no experience with strengthening exercises, see a PT or CSCS in order to obtain quality information prior to starting the program.

​Neuromuscular training can be replaced by balance activities. This can teach patients how to utilize the “somatosensory system”, which is the communication that takes place between the muscles, bones and brain in order to remain in a certain position.

“…neuromuscular exercises can improve knee cartilage quality (glycosaminoglycan content) in middle-aged adults following partial meniscectomy.”

​Every once in a while I learn something new when reading orthopedic research. (just kidding, I am learning every day from the stuff I read). This is a new concept to me. This means that by performing balance training, we can improve the quality of the knee cartilage (meniscus). This is huge because as a health professional, we were always taught that the cartilage has poor blood flow and we can’t really impact healing of this tissue. Who know that balance and exercise were good for you?

“..combining strengthening exercise with exercises aimed at increasing aerobic capacity and flexibility may be the best exercise approach for managing lower-limb OA”

​This has been challenged in the research lately. There is an article by Richard Rosedale (JOSPT 2014) that demonstrates that using MDT can provide superior results. The original advice of diet, exercise and balance is probably still the best advice until more research comes out to show that specific exercises are better than others.

Hope this synopsis was helpful. If you are experiencing knee pain or have been told that you have arthritis, there are options. Come see me at FTR in Joliet, now a member of the Goodlife Family.

Dr. Vince Gutierrez, PT, cert. MDT

903 129th Infantry Dr.

Unit 500

Joliet, IL 60435

815-483-2440

QUOTES TAKEN FROM:

Ackerman IN, Kemp JL, Crossley KM, et al. Hip and Knee Osteoarthritis Affects Younger People, Too. J Orthop Sports Phys Ther 2017;47(2): 67-79.

Get PT 2nd

“out of 137 patients, 100 had been recommended for spinal fusion. After evaluation, the group advised 58 of those patients to pursue a non operative plan of care”

There’s a slogan going around social media saying “GETPT1ST” I don’t know if I completely agree with the saying, but I can’t disagree with that either. The saying could just as well be get PT second. At some point a second opinion has to come in to play for a patient’s dysfunctions or pain. That second opinion, in my belief, has to come from someone without a financial stake in the surgery. This could be a physiatrist, PT, or a separate surgeon, which was done in the study cited.
The take home point is that 58% of those recommended for spinal fusion were recommended to seek a separate form of care, thus advised to avoid the surgery initially. What this means for the patients is that a second opinion should always be sought out, because the person advising a plan of care is advising it from their perspective. I’d love to say that everyone has the patient’s best interest in mind, but I can’t. In that case, the patient must become more educated and advocate for him/herself. For instance, a surgeon does surgery, a physical therapist does physical therapy and a physiatrist does physiatry. We see problems from different lenses and therefore will advise different plans of care for varying presentations. Some patients need surgery and some don’t. Some patients need physical therapy and some don’t. We can’t say PT first because PT is not magic and can’t fix everyone’s issues.
“As clinicians, we bring our own biases into the treatment plan for patients”
Want to decrease unnecessary surgeries? Have a multidisciplinary team do evaluations, researchers say. PT in Motion. April 2017:46.