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DIRECT ACCESS FOR PHYSICAL THERAPISTS
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DIRECT ACCESS FOR PHYSICAL THERAPISTS - June 23, 2000 7:31:00 PM
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wincon
Posts: 65
Joined: June 24, 1999
From: Somerdale, NJ USA
Status: offline
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I am looking for someone to provide input and/or edit the following so that I have something useful in our fight for direct access. I wrote it rather quickly, so I know some editing needs to be done and perhaps someone has some ideas to improve upon the info. present. Thanks! Here it is!
Medical Doctor Control Of Physical Therapy
Why Physical Therapists Need Direct Access:
1. Public Safety 2. To Significantly Improve Care 3. To Significantly Reduce Medical Costs 4. To Foster patient independence which incorporates prevention 5. To prevent unnecessary surgery 6. To encourage scientific thinking among the public.
Anyone with a conscious and considers himself or herself to be a defender of the truth, will critically review the following and come to the only common sense decision one could come up with; Direct Access for Physical Therapist must become a reality throughout the country for the Publics Well Being, physically and economically!
Myth or Fact?
By now it is a well known fact that reimbursement for medical treatments rendered have reached an all time low. Insurance companies are using every avenue 'not to pay'; medical professionals are using every avenue to obtain reimbursement for services rendered. Medical Doctors, as well as other medical and/or allied health professionals, are seeing a drastic reduction in their income relative to the changing medical/healthcare environment. In response to this, many seek other avenues of income. Among the many avenues chosen by physicians involves the providing of in-office physical therapy for respective patients. This may involve direct employment of a physical therapist or it might involve aligning with Business Management Companies who specialize in operating physical therapy centers. Invariably, the selling point to the average lay person (i.e., medical consumer and insurance agent) is that such an arrangement avails patients greater convenience, as well as increased safety and improved treatment relative to physician supervision of provided treatment programs. This sounds good to the average lay person; in reality, this could not be further from the truth.
While patient convenience may be achieved, the safety by which treatments are provided actually decreases considerably; the administration of proper care is can be non-existent because either the physician simply is unfamiliar with real physical therapy or he/she is trying to boost income via the overuse of various modalities; also, the frequency of surgical procedures are likely to increase. According to Dr. Fank Tilaro, Florida, and his supplied references, studies on disc sugery emphasize inappropriate patient selection as the cause for surgical failure. In Kramer's address to the International Spine Society he emphasized that the surgical failed back syndromes is the worst possible scenario a spine surgeon faces. In North America the incidence for this iatrogenic disease is about 15%, compared to 5% with most European countries. Comparisons between the US and Europe indicate that the frequency of surgery in the U.S. is four times greater. Statistics from the Back Pain Outcome Assessment Team copiled from 1979 to 1987 indicate a rapidly growing number of disc excision and fusion operations performed each year, further escalating the cost. Studies of the various surgical procedures largely lack validity and controlled prospective studies are rare. A randomized study by Revel demonstrated percutaneous discectomy has little value and the same is true for laser discectomy. …There are not any studies demonstrating the superiority of one particular surgical intervention and there is no support for adding a fusion to a routine discectomy. (An Overview Of Vertebral Axial Decompression, McKenzie Journal, Vol. 8, #2 - 2000, p. 6; reprinted from Canadian Journal Of Clinical Medicine, January 1998). At this point it is becoming rather cliché to say, "People fix things as they know how to fix 'em"; all the more reason to first allow physical therapists the opportunity to evaluate and treat patient's prior the MD intervention.
Additionally, physician owned practices are likely to hire new graduates as they can be paid less; so too, they can be better controlled by the physicians as physicians realize that they are in the initial learning stages and are typically easily controlled. A learned physical therapist with years of practice and developed skills is likely to apply what they've learned to work best as opposed to what the physician might want applied. It's often financially better to obtain a therapist before he/she learns too much and treats in accord with years of practice continued education and development of skills. Patient's might be discharged too early to meet financial requirements (i.e., cover expenses, make a profit). It is rather obvious that many disgruntled Medical Doctors are going to have no problem over utilizing physical therapy in an attempt to recoup losses incurred via reduced reimbursement for medical services rendered; there certainly isn't going to be any love between the doctors and the Insurance companies so these doctors are not likely to have a problem over utilizing physical therapy and simply claim that 'they are the doctor, they know what's best for the patient.'
The following presents a series of statements for which the reader is to consider myth or fact. Our conditioned responses will likely assume the correct answer, however, when one delves deeper into the reality of the situation, the real answers become realized. As medical consumers, we tend to make assumptions about the capabilities of our treating physician. We all desire appropriate medical care and we want our insurance companies to pay for medical services rendered as they should. Out of shear ignorance, and for some, the desire to use every excuse in the book to avoid paying for services rendered, some insurance companies will make unreasonable requirements in order to provide reimbursement for services rendered. For example, they will often find every reason in the book to require your attendance to numerous medical 'gait-keepers' in the hope that you will simply not want to go through the process necessary to obtain needed reimbursable care and give up; thereby, saving the insurance company dollars. Physicians may have a financial incentive to avoid referral to specialists. However, if the insurance company wished to save 'everyone' money in the long run, they would be supportive of physical therapists ability to see patient's immediately and prior to other medical professionals, until it is clearly discovered that the patient requires the services of another. This is fully in the ability and realm of physical therapy training.
One thing to keep in mind while reviewing the following is that 'we are all human and only capable of just so much.' The question is, 'will your physician admit to his/her own limitations and avail you the opportunity to receive proper care for your condition from a source expert in their own respective field of practice, or will he/she assume to 'know-it-all' and try to control the type of treatment you receive? Will your insurance company avail payment for medical services rendered or simply require you to jump through hoops in order to save money?
While the contents of this article applies to a variety of medical conditions, the focus here will be 'physical therapy.' Review the posted statements and determine whether you feel them to be myth or fact and than note the provided answers along with explanations.
FACT OR MYTH?
1. It is best to receive physical therapy in a physician owned practice and/or a physician
controlled physical therapy practice so the doctor can ensure his patient's get the best physical therapy treatments possible in an MD supervised setting.
Answer: Myth
While one cannot stereotype all such facilities, the medical/healthcare consumer should be on the alert for physician owned practices, as well as practices which involve strict physician control of the physical therapy program being provided to patients. While perhaps 'good intentioned' many, not all, physicians truly do not have any concept as to what 'real' physical therapy consists of. Many still think of physical therapists as 'Glorified Gym Instructors.' They will often assume that HUMER's (Hot packs, Ultra Sound, Massage, Electrical Stimulation, general non-specific exercises such as use of a bike, simple non-specific exercises to perform on an exercise mat) constitutes physical therapy and may not even be aware that they are forcing therapists to perhaps violate state statutes which typically require physical therapists to modify treatments as needed with proper notification to the referral source of said modifications. HUMER's is a very uncomplimentary term ascribed to those therapists and/or supposed 'rehab' facilities who provide the aforementioned treatments solely, or in place of procedures considered in the physical therapy community to be 'Real Physical Therapy."
Medical Doctors typically see patient's on a day-in, day-out basis and are hopefully involved with advancing in their own profession, and therefore, due to time constraints or perhaps even an unwillingness to learn more about the profession of physical therapy beyond their assumed 'beliefs' as to what it is, they remain ignorant as to what 'Real Physical Therapy' is all about. In basic terms physical therapy is an investigational process which seeks to determine faulty mechanical pain producing problems along with the development of treatment strategies based upon evaluative findings. Treatment is specific to the specific problem and at all times attempts to adhere to scientific principles. What many, not all, medical doctors, as well as medical/healthcare consumers do not realize is that in order to know physical therapy, one needs to study and investigate physical therapy concepts and note the willingness of practitioners to evolve with science rather than remain stagnant with old unproven hypotheses and theories.
Within all realms of medical and healthcare there are espoused concepts that can be, and rightfully are, scrutinized by science and certainly one doesn't have to practice within that profession itself to question espoused hypotheses and theories. No physical therapist will claim to know what the medical doctor knows with regard to everything that encompasses being a medical doctor. However, physical therapy is a specialty practice with many subspecialties requiring constant study and practice to develop proficiency. Of course physician practice is subdivided into numerous specialties requiring enormous endeavor and time to become proficient, but one cannot do it all. Medical doctors are 'people' in the end and are only capable of knowing so much and usually stick to their own profession. Unrightfully the assumption is often made that their knowledge base also incorporates 'physical therapy', even without attending courses which delve deeply into the field and practice of physical therapy. Physical therapists have continuous direct contact time with patient's and see how patient's respond to provided procedures and are best able to determine the proper course of treatment. Responses to procedures are noted and discussed with patient's and the treatment can be modified to accommodate responses (i.e., post treatment pain, whether it is in-fact post treatment pain or perhaps postural pain being confused with post-treatment pain, etc.). As the medical / healthcare consumer who is seeing his/her physician for an orthopedic and/or musculoskeletal condition other than having a fracture or the sort, note how much time was spent with you during the office visit and take note as to what was done during the evaluation. Then compare that to the length of time required to perform a physical therapy evaluation and the amount of information shared with you about your findings. It is not hard to see that in 'reality' the time offered to physical therapists to perform evaluations avails them the time to develop their evaluative skills and apply more evaluative procedures. Co-comittently, physical therapists cannot see the volume of patient's your physician sees and thus his/her income is proportionately and typically much lower.
There are conditions, for example, that require that one participate in a functional activity (i.e., using an upright bike, using a treadmill, bending forward, bending backward, etc.), or maintain a particular position (i.e., sitting erect, sitting slouched, standing, etc.) ; the persons low back may need to be held with the lordosis (hallow in the low back) maintained during a particular position and/or movements or activity and then that same position, movement or activity will have to be performed without the lordosis maintained so that a comparison can be made and a clear picture as to 'what is going on' can be attained and the treatment plan can be best applied. Such observations, noting how the patient's spine, for example, responds to sustained stresses and/or repetitive movement stresses to full end-range of available motion, enlightens us as to the significance, or lack thereof, of diagnostic studies. For example, while an MRI might demonstrate a herniated disc on the right, we may only be able to reproduce the patient's symptom complaints on the left, which tells us that the right sided herniation is irrelevant to their pain condition. More details regarding 'MRI's' are forthcoming in this article. A doctor certainly does not have time to distinguish the relevance of MRI findings in their office as they typically spend between 5 to 25 minutes, anecdotally, with each of their patient's due to the high volumes of patient's they need to see to meet expenses and still earn a reasonable profit. They also don't typically provide an evaluation which stresses the area of concern to test the potential relevance of the MRI. Disc herniations do not necessarily cause pain, while some may; this is the purpose of a full physical therapy evaluation which can take between 40 and 90+ minutes.
While many physicians recognize this, there are many who are simply insistent that treatment be limited to HUMER's and believe that physical therapists are nothing more than technicians who are suppose to apply nothing more than what is told to them. This thought process in and of itself is clear evidence of a lack of knowledge as to just what physical therapy consists of. Often if a physical therapist report appears to contradict the physicians findings, even if worded in the most diplomatic means, rather than using that information to clarify the patient's problem to best help the patient, there are many physicians who simply get the attitude, 'who the hell does that physical therapist think he/she is." In reality, the physical therapist is the one who has the time to clarify the mechanical nature (the influences of spinal loading such as assuming various positions, performing various movements) of one's orthopedic/musculoskeletal condition.
This brings to mind the belief that diagnostic studies upon spinal pain patient's are required prior to any physical therapy and/or such studies provide definitive information as to what one's actual problem is. As previously noted, the following statement is a belief among some, or perhaps even many, 'unknowing' physicians and lay persons. Note the following:
FACT OR MYTH?
2. Magnetic Resonance Imaging of the spine should be provided prior to any physical therapy referral, especially with reports of pain traversing down one's limb (i.e., sciatica - pain into either leg perceived to likely be from the back, pain into either UE perceived to be from the neck).
Answer: Myth
Dr. Ronald Donelson relates that his research in the assessment side, looking and documenting pain patterns in response to mechanical stimuli. "Obviously there is nothing more relevant to the problem then the symptoms." "We have to do testing that is both objective and relevant. An MRI is a pretty objective test, but it is an irrelevant test to the symptoms." "The symptoms are what bring relevance to our exam." "Once we've established that these pain patterns exist and they're objective, being relevant, then were interested in where it's coming from, why are these particular things changing the symptoms?" " It implies it is doing something to the pain generator, whatever that generator might be." "One does not have to know where the pain is coming from to get rid of it and successfully treat the origin of the pain" (Personal communications).
According to Dr. Tilaro and his supplied references, "…Adding to the confusion is the belief by too many physicians, patients and insurers that high tech imaging is the standard for establishing a diagnosis. However, the high rates of false positive and false negative findings point to the inadequacies of these studies in identifying the pain generating lesions. Nachemson states: "A confirmatory imaging study is indicated only if surgery is contemplated. Clinical symptoms and findings remain the most important basis for diagnosis. . (An Overview Of Vertebral Axial Decompression, McKenzie Journal, Vol. 8, #2 - 2000, p. 5; reprinted from Canadian Journal Of Clinical Medicine, January 1998). Who evaluate based upon symptom responses which are a direct reflection of the symptom generator and who has time to perform such an evaluation? Physical Therapists.
There are many factors influencing the results of Magnetic Resonance Imaging (MRI). The inner disc (nucleus pulposus; gelatinous-type substance within the confines of the outer hard disc layers) does not have a nerve supply or a blood supply as the outermost annulus does. It receives it's nutrients through imbibation of fluids when the body is non-weight bearing (i.e., sleeping at night). First thing in the morning an MRI will be viewing discs which present with greater fluid content within the confines of the annulus than they would later in the day as weight bearing forces fluids and metabolic wastes out of the disc. One who sits in a physician's office for any appreciable length of time, especially in poorly supporting chairs, is bound to have some disc bulging develop, with or without associated pain. If one receives an MRI when they are asymptomatic, there will possibly be a different picture presenting itself than if he/she were experiencing symptoms at the time.
There is no reason to assume that because you have pain down your leg and you cannot straighten up that you need an MRI or any other diagnostic study for that matter, unless you've sustained a trauma and a fracture needs to be ruled out. It's quite obvious that something is going wrong and you need to have the symptoms addressed immediately as the symptoms are a direct reflection of the symptom generator. Symptomatic responses to applied procedures yield information regarding the safety of applying the procedure and whether the procedure will be of benefit. Often the physical therapist can place you into a position to alleviate these symptoms and change your movement pattern for the better (i.e., you can now straighten-up / stand erect); however, should such procedures be unsuccessful, then diagnostic studies can be performed to make decisions from that point on. It does not take a long time to determine whether the applied procedures will or won't be helpful. In-fact, getting an appointment for the diagnostic test can delay receipt of useful or needed treatment and even placing one into the MRI to receive the test may be a position which can worsen your condition depending upon the extent of the problem. The technicians applying the diagnostic procedure are not typically trained in the effects positions might have upon the spine, nor would such training necessarily avail them the opportunity to place you in a position which won't worsen the problem. Certainly in the case of trauma, x-rays and the sort should be provided first to rule out fractures (broken bones). Physical therapists are fully capable of knowing when to refer out for diagnostic studies.
All to often, this therapist has had referrals of patient's who have had a battery of diagnostic studies prior to receiving physical therapy only to have their pain prolonged. Once they arrive and still in pain, it is not uncommon for immediate positive changes to take place; however, delaying the receipt of physical therapy can make the physical therapists job more difficult. If the patient assumes certain deleterious positions or partakes in deleterious movements while waiting to receive needed treatment and education, the patient's condition can certainly worsen, perhaps to the point of being untreatable by any other means other than surgery. Therefore, the extreme costs of the diagnostic studies and prolonging of the patient's symptoms could have been abated, had the patient had the ability to receive physical therapy, mechanical therapy earlier, rather than later.
Schellhas, Kurt P., et. al. performed a study involving a prospective correlation of MRI and Discography in asymptomatic (having no pain or other symptoms) subjects and pain sufferers. This involved pain of cervical (neck) discogenic origin (from the discs of the neck). Asymptomatic subjects and chronic neck and head pain patients were studied with high-field MRI and discography to compare the tests and determine the accuracy of MRI and discography in identifying the source(s) of cervical discogenic pain. 10 chronic head/neck pain patients and 10 lifelong asymptomatic patients underwent discography at C3-4 through C6,7 after MRI. 17 of 20 normal discs determined normal via MRI, were found to have painless annular tears discographically. In the pain patient population, 11 discs found to be normal via MRI demonstrated 10 of the 11 to have annular tears discographically. Discographically normal discs were never painful in either group. The conclusion was that MRI cannot reliably identify the source of cervical discogenic pain as significant cervical disc annular tears often escape MRI detection. (Schellhas, Kurt P., et.al. Cervical Discogenic pain. A prospective correlation of MRI and Discography in asymptomatic subjects and pain sufferers, Spine Vol. 21, Number 3, pp. 300-312, 1996; The McKenzie Institute USA Journal, Vol. 4, #2 Spring 1996, p. 15).
Jensen MC, Brant-Zawadsk NM, Obuchowski N, Modic MT, Jalkasian D, Ross JS studied MRI of the lumbar spine in people without back pain. They found that many people without back pain have disc bulges or protrusions (inner disc gel protrudes through outer wall of the disc) but not extrusions (inner gel exists the disc wall). Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental. (Magnetic resonance imaging of the Lumbar Spine n people without back pain; New England J Med 331 (2) : 69-73, 1994; July 14, 1994 -- Volume 331, Number 2). [URL=http://www.nejm.org/content/1994/0331/0002/0069.asp]http://www.nejm.org/content/1994/0331/0002/0069.asp[/URL]
What is typically all that is needed to determine rehabilitative potential of patients with pain of spinal origin? A mechanical evaluation performed by a trained licensed medical professional. The McKenzie approach is being utilized by many physicians such as Ronald Donelson, M.D. et al, in Syracuse, New York to determine the need for surgery. The mechanical assessment can help determine the significance of an MRI, or other diagnostic studies, if needed. If surgery is required than at this point an MRI, or other diagnostic studies, can help determine, in correlation with the mechanical findings, the level that needs surgical intervention.
Other References: The New England Journal of Medicine -- July 14, 1994 -- Volume 331, Number 2 Magnetic Resonance Imaging of the Lumbar Spine -- Terrific Test or Tar Baby? [URL=http://www.nejm.org/content/1994/0331/0002/0115.asp]http://www.nejm.org/content/1994/0331/0002/0115.asp[/URL]
FACT OR MYTH?
3. Radiographs (x-rays) noting various bony changes along the spine are not necessarily correlative with your spinal pain problem.
Answer: Fact
Spine, V 22, No 4, February 15 1997 Spinal Radiographic Findings and Nonspecific Low Back Pain Maurits W. van Tulder, PhD,, et al. Conclusions. There is no firm evidence for the presence or absence of a causal relationship between radiographic findings and nonspecific low back pain. Spine 1997;22:427-434 Spine 1997; 22:427 © 1997 Copyright owner Lippincott-Raven Publishers [URL=http://www.lippincott.com/spine/main.cfm?action=contents.]http://www.lippincott.com/spine/main.cfm?action=contents.[/URL]
Witt and Vestergaard, Spine Journal 1984. 166 Subjects - 66 Never had Low Back Pain. 100 Did. X-rays were taken. There were no significant differences in Degenerative Disc Disease, spondylitic changes, etc… X-ray findings did not significantly differ among the groups.
J Orthop Res 12:186-192, 1994 - "Based on epidemiologic studies, it appears that many radiographic anomalies are not associated with pain, including spina bifida occulta, single disc narrowing and spondylosis, most facet joint (spinal joint) abnormalities, sacralization of a lumbar vertebra, lumbarization of a sacral vertebra, hyperlordosis, and Schmorl's nodes
There are apparently a number of study's relative to radiographs which relate that radiological findings are no measure of pain. Have you had x-rays lately? Did you experience a trauma (i.e., fall, car accident, other)? The following relates the reasons for receiving x-rays.
Deyo recommends that x-rays be taken if any of the following circumstances apply:
(Obtained from a colleague affiliated with the McKenzie Institute 1-800-635-8380)
1. Age over 50 years
2. Significant trauma (Fracture risk)
3. Neuromotor (nerve/muscle) deficits (rule out spondylolisthesis (one spinal vertebra slipped forward on top of another vertebra), tumor)
4. Unexplained Weight Loss
5. Suspicion of ankylosing spondylitis (spinal disease condition) (based on a specific set of clinical criteria.)
6. Drug or alcohol abuse (risk factors for osteomyelitis, osteoporosis, trauma)
7. History of cancer (making metastatic disease more likely)
8. Use of corticosteroids (increased risk of infection, osteoporosis)
9. Fever (potentially a sign of osteomyelitis or epidural abscess)
10. Failure to improve with conservative therapy (since 80 - 90% of episodes of acute mechanical pain improve within weeks, those that do not are more likely due to infection, neoplasm or inflammatory spondylitis)
11. Seeking compensation for back pain (x-rays usually needed for legal purposes, not necessarily for medical purposes).
FACT OR MYTH?
4. Many, not all, physicians regard physical therapists as technicians who are suppose to apply treatments as they specify only. However, often physical therapists have more time to spend with patients on a one-on-one basis and often have significantly greater training in determining the mechanical problem of one's spinal pain condition.
Answer: Fact
The problem is that many, not all, physicians feel they have nothing to learn from a physical therapist, they feel they know what physical therapy consists of, when in-fact, they do not. Many haven't afforded themselves the opportunity to learn about physical therapy, yet these same physicians want to own physical therapy facilities and control the physical therapy treatments being provided. Many physicians view physical therapists as technicians who should do only as told and nothing more; despite the fact that 'they don't study or practice physical therapy.' These same physicians often have little time available to spend with each of their patients. Is it reasonable to assume that a physician with limited time can reliably determine the most appropriate course of treatment for your spinal pain than a physical therapist who has the time to evaluate you and gain a clearer picture as to the extent of your spinal pain problem?
(To be continued on next post)
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Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - June 23, 2000 7:33:00 PM
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wincon
Posts: 65
Joined: June 24, 1999
From: Somerdale, NJ USA
Status: offline
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Granted, the medical doctor has full capability to learn and properly apply similar evaluations, however, how many do this; how many have time to apply such an evaluative and treatment procedure and how many actually learn how to provide extensive evaluations such as those taught to physical therapists, namely the McKenzie Approach (http://www.mckenziemdt.org; 1-800-635-8380)? The evaluative and treatment process and time available is inherent in the practice of physical therapy; it is not inherent in physicians practice, especially when they have a high volume of patient's each and every day of their working life. Not many have the time, not many care to learn from physical therapists; not many take the time to communicate to the point of understanding just what the physical therapist endeavors to accomplish with their patient's. Fortunately, physician education and acceptance is growing rapidly, however, not rapidly enough. There are a lot of tough egos to battle through; many physicians familiar with the "McKenzie Approach", for example, are well aware of this and they even wish us physical therapists luck in being able to get to stubborn minded, ego driven physicians. While it is not necessarily correct to paint all physicians with one brush stroke, anecdotally and via communication with colleagues over the years, it is an extremely common and repeated occurrence involving physician ignorance, intolerance and lack of concern for anything the physical therapist has to relate and anytime a physician can be proven to be incorrect in their findings, rather than thank the therapist for doing his/her job, disapproval is expressed for contradicting their findings. Again, many more physicians are opening themselves up to exploring what physical therapy truly consists of and the genuinely concerned physicians are the one's who overcome the 'ego factor' and actually thank the thoughtful therapists for their thoroughness; however, overall it's too little, too late for scores of patients who would have been well served by physical therapists, had the physical therapist had complete control of his/her profession and care of the patient and had seen said patient's from the start of their symptoms.
It is unfathomable to many physicians that a physical therapist has training to discover problems they simply don't have the time during their typical office visit to discover. However, what has to be realized is, that's why physical therapists exist. We are able to spend the time, we are able to clarify the extent of the problem with our evaluations and we are able to develop a program based upon evaluative findings. While this is not necessarily true for all physicians, many are simply unwilling to take communicate with physical therapists and throughout my career I have heard how 'physicians don't read 'em anyway.' It was not uncommon to receive a call months after a patient has started physical therapy with a diagnosis of shoulder strain, for example, and then having the physician call up asking me why we were discussing the potential of possible disc pathology in the neck with the patient. "Doctor, I wrote in my initial evaluation; if you refer to it you will see where I note that the patient's evaluative findings demonstrate a correlation of their symptoms to their neck and not their shoulder." Again, considering the time doctors typically spend with patient's, how many do you think read the physical therapists evaluation? What genuine meaning to they get from it when they do read the evaluation if they are not accustomed to providing 40 to 90+ minute evaluations themselves?
None of the aforementioned takes away from the knowledge and ability required of being a Medical Doctor. To undertake such an educational endeavor is an enormous task. Undertaking the task of becoming a physician and especially continuing on into specialty areas is an unmatched endeavor. It is also a very diversified task; therefore, it is beyond this author's comprehension that there still exists so many physicians who cannot believe that a physical therapy professional is in a better position to evaluate and direct the course of treatment of physical therapy patient's when physical therapists spend 'all' of their time in developing such skills in their particular area of interest.
Physical therapists do not have to diversify into determining the most appropriate means for evaluating and treating various disease states and applying medication and the sort, although the potential effects of medication upon the physical therapy regimen is certainly considered. If there is a fear that one's pain is from an underlying pathological process in a patient's internal organ, for example, the patient's response to the physical therapy evaluation will reveal an atypical pattern of response and then the patient will be referred out to Medical Specialists for further investigation. When a patient's problem is identified by the physical therapist, which will most often be the case, and probably treated, which will most often be the case; just think of the cost savings that would be involved. Costly diagnostics would be avoided, delay of treatment would be avoided, the patient's education and ability to prevent future problems would improve via their personal experience as to how their condition responds to their own positions and movements. Physical therapists have all the time to specialize in their craft and should therefore have every means to decide the course of treatment independently. Physical therapy training extends to the point of knowing when physical therapy won't be enough and then knowing when to refer to the Medical Doctor for conditions that do not behave in a 'mechanical' fashion (i.e., behave as spinal pain would be expected to behave by the medical professional who is trained in mechanical evaluation and treatment of the spine).
Case #1
A recent experience involved evaluating and treating a patient with a history of cancer. She was referred to me by her physician with a diagnosis of sciatica (pain traversing down the leg ascribed to the sciatic nerve). Through application of the a physical therapy evaluation, I was able to determine that her pain was of non-mechanical origin; in other words, I could not influence the symptoms with various spinal movements and positions in a fashion which would be expected in those with genuine sciatic symptoms. I would not expect the physician to have the time to sort through this; however, this is why I and my colleagues are there. To spend the time to examine postural and spinal movement influences upon symptom complaints. After my evaluation, I instructed the aforementioned patient to visit her oncologist right away and speak with her referring physician about having additional diagnostic studies. I spoke with this patient's Oncologist the very next day and explained to him that the patient's symptoms were behaving non-mechanically and thought he might consider providing the patient with a bone scan. The doctor was cordial and thankful; he agreed that a bone scan was called for and immediately ordered the study for the patient.
Sure enough the patient had metastatic cancer within her pelvis which is what I feared. I did not diagnose cancer, I simply was able to determine that the patient's symptoms were not behaving the way a spinal pain patient's pain would expect to behave; correlating this with her history, I realized the potential threat. Had I had the opportunity to see patient's directly, without the requirement of a physician referral; such potential conditions could be discovered sooner. They will not be considered in a physicians office after 10 or 20 minutes; especially with a physician who is untrained in mechanical evaluative processes beyond the basic orthopedic testiing (i.e., quick muscle tests, deep tendon reflex checks, bending forward and backward to simply guage range of motion, quick sensory check if one is lucky). This patient initially had to wait to acquire an appointment with her physician; then she was referred to physical therapy with the diagnosis of sciatica. In such cases, weeks, perhaps days, can make a difference. Had I had the opportunity to see this patient and apply the evaluative process much sooner, this patient would have had more time availed to her to receive the proper treatment she required relative to the cancer. A physical therapists evaluation can last up to and over an hour long; a time frame not within the availability of most physicians; I could have identified the potential problem and had her referred out much sooner so proper care could be administered in a timely fashion.
FACT OR MYTH?
5. Physicians can typically judge the full effectiveness of physical therapy treatments and can
typically judge whether pain reported to have been exacerbated occurred as a result of applied physical therapy procedures or as a result of some other exacerbating factors (i.e., postural, body mechanic related).
Answer: A few physicians have openly acknowledged to me that they don't know how to apply physical therapy, however, they believe they know how to judge effective from non-effective physical therapy. While this may be true in many instances, it Is not necessarily true, and in many instances, it simply isn't true, as the time allotted during a typical physician office visit may be insufficient to get to the 'nitty-gritty', or at least develop plausible theories as to why one's pain has increased. It's easy to accuse the applied procedure of being the reason for one's 'flare-up' and have treatment discontinued by the referring physician; however, considering the time factor the physician has, or hasn't available, and the likelihood that the physician is untrained in mechanical evaluation beyond the standard orthopedic testing, the physical therapist is actually best armed to determine what is most likely the causative factor of the exacerbation of symptoms. Patient's may complain of pain and associate their pain experience with an applied procedure. This therapist has experienced first hand where the physician accepts this information at 'face value' and goes no further in deciphering the likelihood of this hypothesis. Again, keeping in mind the time factor with which the physician has to question you and test you, consider that more time and testing is required to test the hypothesis that an applied procedure was causative in producing post treatment pain.
For example, if a procedure is applied to your neck due to neck pain and you go home and have pain the next day; you might attribute the exacerbation to the treatment out of hand. However, the therapist may be able to cue you into certain positions and/or movements you participated in 'at the time' pain produced or increased which avails other possible reasons for exacerbation. Often a patient will be unaware of their poor body mechanics (i.e., picking something up off a floor by bending at the waist and not bending the knees and keeping a straight spine). Sometimes the patient will not realize they are using poor mechanics until they are in the physical therapy facility participating in various physical activities and the therapist can catch them and point out the poor posture and/or body mechanics directly and immediately. Certainly physicians don't have the time to observe such things as your time in the office is typically spent sitting on the treatment plinth (table). Certainly information can be gathered regarding sitting, but not much else. Therefore, the physician is not necessarily in a good position to judge your pain responses and it has been my personal experience to witness physicians assume particular applied physical therapy procedures worsened someone's pain condition, when the evidence might have shown otherwise had a thorough investigative process of questioning and observing taken place. Pain provides information to use as a guide. There is a Spinal Pain 'Guide' called the Traffic-Light-Guide physical therapists and many other medical and/or healthcare providers are utilizing or beginning to utilize which is based upon common sense and requires time to utilize during the evaluative process and some time to train a patient to utilize independently.
The same can be said for when benefits appear to have occurred the day after a treatment application. For example, if I treat someone's neck and I notice immediate increased range of motion and associated decreased pain during the motion, I can be pretty certain that what I did helped. However, if the patient's cervical range of motion did not improve until the following day, what I did may have contributed to this positive outcome, or perhaps education regarding sleeping postures and other similar education might have contributed, or perhaps it was nothing more than spontaneous remission relative to the natural resolution process that lead to the improvement. The natural history of spinal pain needs consideration. Another example of how an activity can potentially be blamed for one's spinal pain, when it might have nothing to do with the problem is as follows: if you played a bout of Tennis, then sat down on the bench at the side-lines and began to experience pain, you are likely to attribute your pain to playing Tennis. If you inform the doctor of this, don't be surprised if he/she also attributes the pain to playing Tennis and tells you to stop.
This is not to say that all doctors would jump to the same assumption, however, it is not surprising to see a physician in-fact do just that. What considerations are missing? If you play Tennis and experience no pain during the activity, it is unlikely to be the causative factor in the pain experienced post activity. Note that when one participates in exertional activity, the muscles and joints become warm and more susceptible to postural stresses. Those joints are therefore more prone to the stresses of poor posture and/or body mechanics. If you sit on a bench and slouch, you are creating a force upon the body's joints, in particularly the spine, which can produce postural pain which can lead to even worse conditions if left unchecked. Simply correcting the posture while sitting may have been enough to correct the problem and you might not have to discontinue playing Tennis at all. Pain needs close evaluation and scrutiny. Is the pain producing or is it there and is it increased? How is the pain influenced by assumed positions and during movements; what are you doing at the time pain ensues or increases? How long is one in said position(s) and/or participating in said movement(s) before the pain produces or increases? All of this, in addition to other pertinent questions that arise during the patient interview process, provides valuable information as to how symptoms are influenced via positions and/or movements, thereby providing information about the symptom generator and how it is influenced with said mechanical forces (positions and/or movements).
The traffice-Light Guide is one of the considerations used during the McKenzie evaluative process. Van Wijmen reports that repeated movement testing is essential to determine the stability of repair following tissue damage by derangement or trauma. This applies not only to spinal structures but also to soft tissue elsewhere in the body. During the healing process natural tension applied to the repair is necessary to prevent the development of a painful and weak scar resulting from cross linkage of collagen (Evans 1980). However this tension must not be of such a degree that healing is disrupted. The traffic-light-guide as introduced by Wayne Rath, PT, DipMDT (1989) provides an excellent assessment tool for therapist and patients alike. (Van Wijimen, P., The Use of Repeated Movements in the McKenzie Method of Spinal Examination The McKenzie Institute, USA Newsletter, Vol. 3, #2 Summer, 1995, p. 24).
The traffic-light-guide is a guide developed to help direct the clinician in determining what positions and/or movements are safe, precautionary or dangerous for patients' while using the McKenzie evaluative procedures. It also provides patient's with a self-testing mechanism to ensure they know what is good, potentially bad and bad for them. It is based on symptom responses to test movements and positions, is extremely valuable in providing patient and practitioner comfort and trust, and providing information related to the status of one's condition while using McKenzie procedures. If a patient can assume a position and/or perform a movement without pain and is no worse just after that movement, that's a "Green Light", proceed without fear of damage. If a patient can assume a position and/or perform a movement, produces or increases pain during said position and/or movement, but this pain does not remain worse as a result, proceed with caution. Of course, pain producing or increasing while assuming a position and/or participating in a particular movement which results in a worsening of symptoms which remains for several minutes should be avoided. This puts things into basic terms, however, the evaluative process is certainly time consuming and comprehensive and therefore sufficient time with a mechanical trained practitioner is required to minimize assumption.
There are instances in which increased pain in the low back is desired. Studies examining the centralization phenomenon (See section of Centralization), demonstrate the benefits of such an experience. A patient who has one particular type of back problem which causes pain in the leg would be better off having more back pain and less leg pain rather than leg pain and no back pain, for example. There are occasions in which treatment calls for producing leg pain and other cases in which doing so would be detrimental. If a physician is left uneducated as to expected mechanical response to assumed positions and movements, then they will be left in a position in which that are rather incapable of determining the true extent of benefit. As brilliant as many physicians are, they cannot possibly know it all and in reality physical therapy is not their profession; they don't typically know physical therapy.
All of this is why physical therapists need direct access to the public; the ability to receive patient visits without the need for a physician referral/prescription. The public is better able to acquire timely needed therapy and referred to MD's only as needed, which is rather easy to determine; thereby decreasing the volume of patient's seen in a doctors office, allowing the doctor to spend more time with his/her patient's as well. As physical therapy procedures, such as the McKenzie Approach, starts with the most important foundation, that of starting from the point of how one's condition responds to independent movements and positions provides valuable information as to the status of one's condition (i.e., active problem such as a potential disc bulge for example, versus a healing process problem, tightly healed damaged tissues which need to be stretched out basically). From that point on, the determination of whether manual forces are required are determined and if they are so determined they can be applied with increasing force as proven needed. At such a time manipulation is seen called for, which is quite rare in the experience of most McKenzie trained practitioners, then certainly such procedures can be utilized as the need is demonstrated. Should applied procedure fail to provide relevant information or produce relevant changes, the patient can they be referred to a physician or other medical and/or healthcare provider for the next step, which might be some other form of manual therapy or perhaps diagnostic studies.
FACT OR MYTH?
6. Physician prescriptions for physical therapy typically provide an accurate diagnosis of the patient's spinal pain condition and are likely to be more accurate than what a physical therapist can determine independently.
Answer: While on occasion this may be true (may be lucky enough to acquire a physician who has kept up-to-date with physical therapy procedures), it is very often, untrue. This goes for the spine as well as the rest of the body when sufficient time is not availed a patient for a complete and thorough evaluation and sole reliance is placed upon diagnostic reports. With regard to the spine, recall what was already discussed about Magnetic Resonance Imaging Study results and that herniated discs and/or bulging discs may or may not produce pain. A prescription reading, "Herniated Nucleus Pulposus" (disc) may or may not be correlative with the persons problem. For example, a right sided herniation will not produce left sided symptoms, however, it is not uncommon to read a report which relates that the herniation is on one side, yet the patient experiences symptoms on the opposite side, therefore, it is irrelevant. The herniation may have been noted to be located at the 3rd lumbar segment, yet the symptom distribution presents as though coming from the 5th lumbar level. It is quite common to have a prescription which reads, "Lumbar or Cervical Strain/Sprain." Such a diagnosis is not a diagnosis, but rather information relating the mechanism of injury; something that can be found out directly by the patient and does not require a piece of paper informing the therapist of this. It is not uncommon to receive a diagnosis of spinal strain/sprain when in-fact the mechanism of injury had nothing to do with a sprain or strain or even any kind of direct trauma, however, the diagnosis is utilized as a 'catch-all' diagnosis. One is needed, so it sounds as good as anything else. Another 'catch-all' diagnosis is muscle strain or muscle spasm. Note the following comments regarding muscular involvement relative to spinal pain.
Kuslich, et al: What About The Role of Muscular Tissue? It's assumed by many authorities that weak and strained muscles are a common source of lumbar pain. If this assumption is true, Kuslich, et al ask, "Why do we see backache in many patients who have strong muscles, and why does low back pain last so much longer than other commonly overused and strained muscles? A few isolated cases of compartment syndrome are noted to have been published and microscopic atrophic changes have been observed in some patients which low back pain, but we find no published accounts of muscle tears and hematomas in patients operated on for low back pain. Most observers have found very little evidence of muscle pathology that cannot be easily attributed to disuse. Kuslich's studies have demonstrated that muscles to be rather insensitive. (Kuslich and Ulstrom, The Tissue Origin of Low Back Pain, Orthopedic Clinics of North America, Vol. 22, No. 2, April 1991).
During Kusliches study involving 193 surgical patients being operated on for stenosis and/or herniated nucleus pulposus, he found that gentle pressure never produced pain. Forceful stretching at the base of the muscles, especially at the site of blood vessels or nerves, or at its attachment to bone, usually produced a localized low back pain. This pain varied with the amount of pressure and stretch applied. The pain was described as sharp and rarely simulated the deep, dull ache of lumbago. We were unable to observe any evidence of gross pathologic changes in the muscle, and concluded that the pain was probably derived from local vessels and nerves, rather than the muscle bundles themselves. (Kuslich and Ulstrom, The Tissue Origin of Low Back Pain, Orthopedic Clinics of North America, Vol. 22, No. 2, April 1991).
Richard L. Aptaker, DO: Muscle strains usually resolve within a few days to a couple of weeks, ligament sprains may take up to a couple of months, and disk injuries or herniations with radiculopathy can take 3 to 6 months for full recovery. Chronic pain beyond 6 months is likely associated with a degenerative process, be it in the disk, bone, or ligament, or from subtle mechanical instability caused by faulty posture or biomechanics. Reference: Neck Pain: Part 1: Narrowing the Differential THE PHYSICIAN AND SPORTSMEDICINE - VOL 24 - NO. 10 - OCTOBER 96 - [URL=http://www.physsportsmed.com/issues/oct_96/aptaker.htm]http://www.physsportsmed.com/issues/oct_96/aptaker.htm[/URL]
McKenzie: "The source of power and cause movement can indeed be over-stretched or injured." "This requires a considerable amount of force and does not often happen." "Muscles usually heal very rapidly and seldom cause pain lasting for more than a week or two." "However, whenever the impact of the injuring force is severe enough to affect the muscles, the underlying soft tissues and ligaments will be damaged as well. In fact, usually these tissues are damaged long before the muscles." "Although the belief is widespread, rarely can pain in the back be attributed to torn or inflamed muscles three or four weeks after injury." Should there be any doubts in this regard, the exclusion of muscle or tendonous structures as the source of pain should be established by a combination of resisted muscle testing as described by Cyriax, and repetitive motion testing." "Of course local muscle tearing or contusion can occur in the region of the upper back and neck, but the natural history of muscle injury in other parts of the body would suggest that pains from this source would resolve spontaneously in two to three weeks." (McKenzie, R., The Cervical and Thoracic Spine, Mechanical Diagnosis and Therapy"; Waikanae, New Zealand,. Spinal Publications Ltd.; 1989, p. 98)
Dr. Kuslich: "Muscles do not cause the very deep pain people get with back ache. There is virtually never a case of primary muscle back pain." (The McKenzie Institute, USA, Educational Update and Second General Membership Meeting, July 15, 1995).
Saunders: "Spinal disorders primarily of muscular origin are uncommon, there is no neurophysiolgoical reason for a normal muscle to spontaneously go into spasm." "Primary muscular disorder may be classified as strains, contusions and inflammations.
Dr. Cyriax: "Muscle spasm is a symptomless secondary phenomenon brought into play to guard
the joint and does not require treatment." "Attention should be brought to bear on the causative
lesion, on reduction of which the muscle spasm will be abolished." Attention should be brought to
bear on the causative lesion, on reduction of which the muscle spasm will be abolished.
(Cyriax, J., Illustrated Manual of Orthopaedic Medicine, Butterworths, p. 144).
Kisner and Colby: Acknowledge that treating only the spasm doesn't relieve the source of the problem. They acknowledge that one does not have an attack of muscle guarding or spasm unless there's some other disorder present. (Kisner and Colby, Therapeutic Exercises - Foundations and Techniques", F.A. Davis, p.470 ).
Wayne Rath, PT, DipMDT (McKenzie faulty and World Wide Lecturer): "I rarely look at a patient that's stuck in a vicious cycle of muscle guarding, decreased circulation, increased metabolite retention and that being the source of the problem." "I invariable look at any muscle guarding, spasm as a symptom of an underlying problem." "If I'm an emergency room doctor with a patient who has an acute abdominal spasm with a fever and pain in the right quarter/lower quarter, am I going to treat the muscle spasm or am I going to get that appendix out of there as soon as possible?" "If you get at the underlying mechanical problem most of the tenderness that's abnormal will fade."
Here is another diagnosis which attempts to be a bit more descriptive, but doesn't quite hit the mark, 'Brachial Plexopathy' (a problem with the brachial plexes); and another popular one, 'sciatica' (leg pain perceived to be from the low back); the list of supposed diagnoses goes on and on. Simply look at your own prescription for physical therapy provided to you by your physician. Interestingly, and as previously noted, an extremely comprehensive study was undertaken in Canada due to the increasing incidence and escalating costs of treating pain of spinal origin. This study was presented as a special supplement to the Spine Journal (Spitzer et al, 1987), 'Scientific approach to the assessment and management of activity-related spinal disorders: A monograph for clinicians', report of the Quebec Task Force (QTF) on spinal disorder. The workers compensation Board commissioned this report. The QTF consisted of a Multidisciplinary team of scientists and researchers for the purpose of investigating therapeutic intervention in the treatment of spinal disorders. To this day the report represents the most comprehensive scientific analysis of lumbar literature ever performed. Recommendations were provided which involved the universal adoption of a classification of spinal disorders based on simple clinical criteria that represent most cases, which are seen in clinical practice. These recommendations support the concept of classification of non-specific spinal disorders by pain patterns, and attach to the first four groups, (categories describing spinal pain conditions), patterns almost identical to those adopted by McKenzie in 1972 and described in 1981 (McKenzie 1981).
(to be continued on next post)
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Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - June 23, 2000 7:34:00 PM
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wincon
Posts: 65
Joined: June 24, 1999
From: Somerdale, NJ USA
Status: offline
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The authors of the report have concluded that pain pattern classification is likely to provide answers in our search to improve treatment methods. (McKenzie Course Materials; Institute information). So what is the largest group of medical professionals utilizing said classification systems? The McKenzie classification system, as well as the Quebec Task Force classifications are utilized throughout the world by non-other than physical therapists; however, more and more chiropractors, and other allied health and/or medical professionals are beginning to ascribe to mechanical treatment and diagnosis and practice this common sense system on a daily basis. However, as of this date, physical therapists comprise the largest group of medical/healthcare professionals utilizing these systems of classification. Physicians do not typically provide such mechanical diagnoses, unless they've received training in The McKenzie Approach, or more recently, the 'Duffy-Rath System' which also utilizes mechanical concepts in association with the Quebec Task Force classification system. Even if trained, few physicians are likely to have the opportunity to provide the full evaluation as it is suppose to be applied due to inherent time constraints in their daily work schedule. Many of these well informed Medical Doctors rightfully rely upon the physical therapist to provide such evaluations and these very physicians will utilize the outcomes of said evaluations and treatments as a key determinant as to whether one will require surgery. As previously indicated, many educated physicians have found exactly what Dr. Martin Knight has found. Dr. Knight; Consultant Orthopedic Surgeon, The spinal Foundation, Rochdale, England. "Before anyone does surgery, patients should have a full course of McKenzie Routines and more advanced techniques, beyond that, just as all patients in my group has had." (Overview and Validation of the McKenzie Method, Video distributed through OPTP, Minneapolis, MN, 1995).
As hard as this may be to believe for those who thought physicians had 'all' the answers, the reasonable person cannot justifiably claim that physicians are typically providing essential information to the physical therapist prior to the physical therapist administering a physical therapy evaluation and developing a treatment program; unless of course, the prescription involves a patient who has just undergone a surgical procedure requiring information relative to associated precautions. In this case, the physical therapists is more apt to receive useful information to better gauge a patient's rehabilitative program. However, also consider that some post-operative rehabilitation may be unduly delayed; this is when the patient may have to do some investigation him/herself to ensure rehabilitation starts as soon as feasible. This means delving into the available research and presenting it to the attending surgeon for an fully education decision to be made. Physicians can serve as extremely important collaborators if and when their services are proven to be in need. When the physical therapist is unable to achieve desired effects, or is finding that one's condition cannot be clarified mechanically (cannot find an organic reason for presenting symptoms) this is when the medical doctor becomes invaluable; this is when he/she is most needed. If anything, keeping them in the position of 'gait keeper' is detrimental to the patient's right to receive quality care, the correct care, in a timely fashion.
Here is just one in innumerable examples of how a physician can come to the wrong conclusion due to lacking a mechanical foundation as his focus. The following patient was referred to me for physical therapy treatment. The prescription called for Myofascial Release (a specialized form of soft tissue procedures rarely required by myself in my years of practice), ice and electrical stimulation for pain and supposed inflammation that was believed to have been observed. First thing the reader should note is that soft tissue procedures will always take a back seat to underlying mechanical disturbances with regard to spinal pain. While the following may be somewhat technical for some readers, enough information can be understood to get the point. Note the following:
Case #2
Terms:
Cervical = neck
ROM = Range Of Motion
ADL's = Activities Of Daily Living
Apophyseal joint: The technical name for a spinal joint, sometimes referred to as a 'facet'
joint.
Glide(s): A type of spinal joint movement imparted by the therapist to the spinal joint as
part of a mobilization procedure.
Posterolateral = behind and to the side
Derangement: An internal vertebral segment problem which is theoretically believed to
involve a spinal disc and for which many studies appear to verify. It presents with specific
criteria during evaluative processes which the examiner looks for.
Dear Dr.:
Ms. XXXX was seen this day for a physical therapy evaluation. The patient's most relevant evaluative findings are as follows.
SUBJECTIVE:
This patient is a 10 y/o female who attended physical therapy with her mother. The patient reports ensuring pain yesterday morning while lacing a light blanket down while simultaneously turning her head toward the right. The patient reports pain with right rotation, looking downward (flexion) and looking upward (extension). Her sleep is disturbed secondary to pain and has to sleep supine.
Current Symptoms: Patient denies pain at rest and remaining completely still presently, however, movements as noted above will produce significant pain.
PMH: The patient and her mother deny knowing of any other significant past or present medical history and considers her health to be generally good otherwise.
OBJECTIVE:
OBSERVATION: Acute cervical deformity - Significant Head tilt (chin toward right), elevated left shoulder; significant forward head posture; protracted shoulders, left greater than right.
ROM
Cervical Spine: Cervical Extension (Bending head backward): Moderate obstruction; Cervical Rotation Right and Cervical Lateral Flexion Right (right side-bending): Moderate to Severe Obstruction (Post treatment, cervical mobility/ROM significantly improved; see below).
TREATMENT
Instruction with proper posture and body mechanics as it relates to ADL's; provided informative materials in this regard. Manual Procedures: Cervical traction with retraction; cervical traction with right lateral flexion with addition of mobilizations then right rotation with addition of mobilizations - procedures performed in supine and sitting; Mulligan Nags and SNAGs (A specialized form of mobilization of spinal joints to encourage them to function as their anatomy would allow / maximizing normal function; NAG's: Natural Apophyseal Glides and SNAG's: Sustained Natural Apophyseal Glides) followed by thorough instruction with self mobilization procedures utilizing a towel to stabilize the cervical segments and to apply overpressure into right rotation and right lateral flexion; postural stretching relative to forward head, protracted shoulders, slouched posture.
The patient was able to demonstrate proper use of towel for independent self mobilizations/stretching along with assistance from her mother. Patient and her mother were instructed to monitor for pain producing in correlation with positions and movements and length of time required to produce symptoms while participating in any particular activity or posture/position. The patient and her mother were instructed in the following: Use of a towel roll for sleeping and to adjust thickness as needed; instructed to review old photos involving pictures taken directly in front of her daughter to see if any asymmetry can be detected. The patient and her mother expressed an understanding of information discussed and her home program and will keep me posted as to XXXXX's progress.
ASSESSMENT
The patient appears to be presenting with a right posterolateral (the back of the neck and to the right side of the neck) cervical derangement (i.e., theoretically cervical disc lesion) with a significant lateral component. This is evidenced by the how quickly the patient's cervical range of motion and cervical posture improved and by the fact that the patient only experienced right posterolateral cervical pain production at the end-range of flexion and not sooner during the motion. Cervical Extension, right rotation and right lateral flexion all significantly improved post treatment. Patient presented with significantly improved symmetry although at least part of her posture may be related to previous normal asymmetry along with protective guarding feeding into the asymmetry and perhaps influenced by the derangement itself.
Please feel free to contact me at any time with any questions, suggestions and/or concerns regarding the care of this patient.
Best Regards,
Mitchell A. Hackerman, PT, Cert. MDT, NMT, CMT, CFT
The physician questioned me with regard to my treatment selection and I had to inform him that I simply had to focus upon the immediate mechanical needs of the patient as to do otherwise could jeopardize the potential well being of the patient. Also to note is state law requires I modify the treatment as seen needed and to notify the referral source of such modification, which is what I had done. The inflammation the doctor spoke of was nothing more than tissue thickening relative to the patient protectively guarding with her muscles to avoid producing pain. To assume that such a deformity is the result of pure muscular involvement simply does not make sense. Once the acute deformity was properly treated, pain dissipated as did her deformity. There was no swelling as claimed and no inflammation in the left scapular (shoulder blade) region as was claimed. A doctor trained in mechanical therapy, who has the time to apply such an evaluation, would have recognized this right away and the overlying soft tissues would not have been a concern. However, by doing what I know is right, I jeopardize my professional relationship with the referring physician. This is just one in innumerable cases involving erroneous findings due to lack of mechanical evaluative knowledge, how one's movements and positions influence their spinal pain condition. Do I think the referring physician is stupid? Of course not; again, I wouldn't pretend to know what he knows with regard to his profession. However, as with most physician's I've personally encountered, they are mechanically uninformed and simply would not have the time to provide such an evaluation even with proper training. Fortunately the doctor was able to note how quickly the patient responded to the provided treatment and therefore did not vocalize too much dissatisfaction; however, other incidences of a similar nature have occurred which has yielded some frustration on the part of the physician.
Case #3
This patient has an MRI report which discusses hypertrophied facet joints (enlarged spinal joints); foraminal and spinal canal stenosis (narrowing of bony openings where spinal nerve roots exist the spine, as well as narrowing of the canal itself which envelops the spinal cord). It was even noted how some bony material was very close to the L5 (lumbar spinal nerve root which emanates from the 5th lumbar vertebral level). This patient has never had back pain and he has been experiencing 'achiness' and the sensation of weakness in both of his legs (just below the knee, lateral and posterior calf and front of the shin) , however, mostly the left leg. It's only mild in the right. In such a case, one would expect that certain strategies involving the spine would either increase, produce, reduce or possibly eliminate the patient's symptom complaints. However, every procedure involving the spine failed at having any influence. Recall that diagnostic findings are not always correlative with one's symptom complaints; however, an unscrupulous surgeon, or one is just plain ignorant, could utilize the findings to justify surgery.
I tested this patient with each visit and whether I had the patient move his spine through complete and full ranges of available motion or whether I made in stay in one position while his spine was held 'at' the end range of it's available motion (i.e., bending forward and holding it; slouch sitting, lying on the stomach while the trunk/spine is extended fully with added overpressure into this direction, etc., etc..) nothing had any effect upon his symptoms in any way. I tested him for possible circulatory compromise in the legs which can often produce such symptoms and all such procedures failed reproducing the patient's symptom complaints. He even took my suggestion for safety and had a vascular work-up (testing beyond what could be done in a physical therapy facility; specialized vascular tests). However, manual procedures applied to the patient's knee joint is the only procedure which had any effect whatsoever. Mobilization to the knees immediately eliminated his symptoms and he remained symptom free. Upon the patient's last visit with me, he complained of 'aching' all day; that is, until I mobilized his knee joint, at which time immediate relief was experienced. The patient visited the referring physician and this information was clearly related to the physician in a detailed report. The patient even told the doctor himself of how well the knee mobilizations eliminated his symptoms. What did the physician do? He discharged him from therapy and told him that he would provide a cortisone injection into the patient's spine in a week. What should have been done is that the physician should have taking steps to further explore the potential for the patient's knees to be causing his symptoms. I am not so bold as to absolutely discard the physicians original diagnosis, however, there is sufficient indication to check the knees more closely and at least I am willing to simply say, "I just don't know for sure." No body can say for sure at this time; however, one has sufficient information which places some doubt as to whether his spinal diagnostic findings are relevant to his symptom complaints and the effects of mobilization of the knees, as well as other tests provided, should cue the physician into at least examining the knees further. I have yet to receive a call from the patient's physician to discuss the potential of knee involvement.
Case #4 - May as well be called "The Case That Is Repeated On A Continuous Basis On Into Infinity"
Continuous referrals of shoulder strains or muscle strain of the neck or muscle spasm of the neck often turn up to be problems involving the spine itself (spinal joint segment, disc, joint). Again, given the allotted time the average physician has and the likelihood that the physician hasn't received training in mechanical evaluation and treatment of the spine, he/she would be unlikely to decipher the mechanical condition; yet physician's claim they need to be in control of patient's physical therapy programs. Perhaps this hypothesis should be tested. Simply select a group of people complaining of neck and/or back pain. Have some of these patient's go through the processes required of their respective insurance companies. Some plans require a gate keeper to the gate keepers. In other words, some insurance companies require the patient visit their primary care physician first (the first gate keeper). They do this; either the primary care physician will refer them directly to a physical therapist (direct care provider who actually treats the patient's condition based upon the physical therapy evaluation), if the patient is lucky, or the patient will be referred to an orthopedic specialist (the second gate keeper), perhaps even a neurologist or neurosurgeon (other potential gate keepers before the physical therapists can start treating the patient beyond oral and intravenous injections). However the bureaucracy is set up with one's particular 'Delay' of Healthcare plan. Have the other set of patient's attend visits with physical therapists, preferably those who have had mechanical training (i.e., McKenzie Approach). Keep in mind that physical therapists generally have a much longer time available to them to perform a more extensive evaluation. The patient's should then have the opportunity to do what the other group has done; those who visited the gate keeper(s) first, then go to physical therapy, while those who were able to attend physical therapy first, then go to the gate keepers, which in this instance and group of patients, have had their gate keeping privileges revoked for the sake of the integrity of the study. The patient's should record everything that is done to them and their visits should be timed. Preferably the sessions should be recorded with hidden cameras and taped with tape or digital recorders. Sufficient time should elapse so that treatment can be monitored. What will be discovered is there is little use of the medical doctor in the process and that the physical therapist is capable of deciphering which patient's need to see the medical doctor and which are amenable to physical therapy treatment and education. All potential hidden variables which could skew the study's findings should be uncovered and considered and minimized prior to the start of the study. In the case of such a study, it's hard not to consider the outcome 'already known.'
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Discussions regarding treatment's for spinal conditions via medical doctors does not typically extend beyond their prescribing physical therapy, providing patient's with various injections and/or providing oral medications and/or surgery. Injections, oral medications and surgery all have their place, however, it has been my anecdotal experience, and the experience of colleagues, that limited information, insufficient information is being provided to patients; often patient's are sent home to allow the natural resolution process do it's job, in which case the patient learns nothing about how to potentially control their condition and/or prevent recurrence and how positions and movements influence their condition. Statistically speaking, 90% of back pain returns within 3 years. Approximately 44% of patients with low back pain are better in one week, 86% within one month, and 92% within two months. (Dixon, A.St.J. (1976), "Diagnosis of low back pain", in: "The lumbar spine and back pain" Ed. M. Jayson). The most important reason one seeks medical attention for most spinal pain is so they can learn through personal experience how to control and/or prevent recurrence of their condition which 'could' become worse with each occurrence. Within 3 years 90% of LBP will return (Spine Journal Vol. 1 No. 1; Rothstein); Out of that 90%, 35% will 35% will recur with sciatica.)
If you're sent home with only medication and rest until resolution, what have you learned that could potentially benefit you in the event of a relapse? Injections (i.e., epidural, cortisone, etc..), may often have their place in treatment as well, however, all too often, it is provided prior to appropriate physical therapy / mechanical treatment which can certainly skew findings as the patient's perception of their symptoms will be altered. Realize that if physicians really don't know what physical therapy truly consists of, they won't realize that they are suppose to wait until the therapist notifies them that something else needs to be done as the therapy isn't getting anywhere. Doctors will often inject while a therapist is in the midst of monitoring symptom behaviors to a prescribed position the patient is suppose to assume at home which would avail important information to the therapist as to how said position is influencing the persons condition. Yes, many, not all, doctors will take offense to a request to hold off on the injection; so it's a pop shot as to whether a therapist is dealing with a pleasant open minded physician or one that hasn't any consideration for what a physical therapist has to say. The latter could likely get the therapist into hot water with his/her employer. Recall that people apply what they know and nothing more. If a physician only knows how to prescribe medications, provide injections and/or perform surgery, that will be the foremost though in their mind and that is what they will likely use. In a physical therapists mind and other allied health professional's mind, the foremost thought is to determine a way to prevent the need for the physician applied procedures, as they tend to be more invasive, often unnecessary and less educational in nature. For example, how often do you suppose anti-inflammatory medication has been prescribed to patient's who do not have constant pain? Inflammation implies a chemical type of pain which also typically engenders constant pain. If your pain ONLY occurs when you move in a particular direction at the end range of the movement, this is unlikely to be relative to an inflammatory process. As antiinflammorties have an analgesic component to them (pain reliever), it may work to some degree, however, with the pain pattern I just described, it's hard to rationalize why any medication is even needed. End-range pain such as when bending forward can be from nothing more than tightly healed tissues which simply need to be stretched out; however, often, medication is a quick and easy way to make one's way to the next patient in line. Again, I will not use one brush stroke to paint the entire medical profession; however, who can honestly say these types of things 'don't happen?' It's truly not that difficult to see that the public should be allowed to visit physical therapists without a physician prescription, aside from specialized post surgical procedures, nationally, especially considering the success with this in the 30+ states that allow this and especially considering the success with this in the Military and in other countries around the world. It's a matter of quality of care and timely care.
I could literally go on for hours typing case incidence for which the physical therapist was the one who discovered the real nature of patient's musculoskeletal problems, have avoided the need for costly diagnostic testing and needless visits to orthopedic and/or neurologic specialists, who specialty is, "Surgery." How do people fix things? As they know how! If a therapist is lucky, he/she will be dealing with a communicable physician, however, all to often my experience and the experience of most of my colleagues many physicians are either too busy to communicate, have no consideration for what the physical therapist has to say because of ignorance of the profession, plain and simple non-communication for a variety of egotistical reasons and/or time constraints. Many physicians will even assume they are able to figure more out in their 10 minute time spurts than a PT who spends anywhere from 40 to 90+ minutes with a patient with each and every visit. Physical therapists practice full evaluations everyday and the evaluative process is more complex than that provided by the average physician. If this seems hard to believe, conduct an experiment. Go out yourself to several physician offices, time the meeting, note what was done with you and what has been stated. Did they refer you out for diagnostics right off the bat despite the fact you weren't involved in a trauma episode or the like? Did they simply have you bend a few times, test a few reflexes and they send you home with medication? Then go to a physical therapist who has freedom of movement to do what he/she has been trained to do. Note the information provided and the time spent. Suddenly the preconceived notions as to 'who is the one the patient is better off seeing from day one of a musculoskeletal problem becomes quite evident.
Conclusion
This author respects the skills and the enormous educational endeavors required to become a medical doctor. The undertaking of such an educational task is certainly admirable and worthy of great respect, however, less we forget, doctors are still human and can't possibly know everything or do everything. As cliché' as though it may be, 'they are only human'. Physician's prescriptions are often typically and incredibly vague and provide little useful information to the physical therapist, unless the patient has had recent surgery. This is why we have nurses, this is why we have physical therapists. More and more physicians are opening physician owned physical therapy offices to offset the losses incurred in today's healthcare environment of reduced reimbursement and micro-managed healthcare. Many, not all, physicians believe they know what physical therapy is and really don't know what It is. You are more likely to receive the best physical therapy care from a physical therapist owned facility than a corporate or physician owned entity; especially if treatments are not dictated by the physician. Physical therapists have the time to apply the most thorough evaluations and develop a treatment plan based upon evaluative findings and physical therapist owned facilities don't typically have the financial burden to deal with to the extent big corporate entities do. This is what the physical therapist goes to school for; to apply 'their' craft in the way they have been trained. A physician does not receive training in physical therapy beyond perhaps concepts and some discussions relative to application. A physician typically wouldn't have time to perform a thorough mechanical and/or physical evaluation with each of their patients. Even if they took it upon themselves to learn certain evaluative procedures that are typical of physical therapists and/or trained mechanical practitioners, they still would need the appropriate time to conduct an appropriate evaluation which can last from 30 to 90+ minutes; at least 1 hour. How many physicians do you know who have such time available to spend with their patients? Big corporate entities have big corporate expenses and the push for profit comes from many sources, whereas the physical therapist owned facility would not typically involve a multitude of people trying to share the same piece of the pie. When one is trained in physical therapy, you apply what you've been trained to apply. If one is trained in business, the business aspects will take precedents. Ignorance can be bliss (i.e., you know you need dollars to operate the business and make as large a profit as possible; you don't have the knowledge of physical therapy to get in your way of making a buck.)
The pubic should contact legislators in their communities and at higher government levels and insist upon laws being passed which will allow patient's initial contact with physical therapists which subsequent treatments. This will decrease the volume in physician offices, avail timely treatment as needed, prevent the problems often associated with delay of treatment; and prevent the needless application of costly diagnostic studies. The only reason, the absolute ONLY reason why other medical and/or healthcare professions endeavor to prevent this is based solely upon the potential influence upon their personal economics. With regard to the chiropractic community, some friends of mine who are chiropractors have openly admitted this to me. Any physicians who believe that there is a genuine danger to the public by allowing the public direct access to physical therapy without a physician prescription are simply oblivious to the realities of physical therapy and the scientific literature. Physical therapists are often viewed by physicians, not all, as technicians to apply whatever procedure so requested by them and nothing more. However, as the doctors daily activities involve seeing patients day-in and day-out without the time to consider the evolution of physical therapy, many simply do not realize their ignorance to what physical therapy actually consists of. One need only look toward the Military and 30+ states and other countries (i.e., New Zealand, United Kingdom, Australia, other with the same basic training provided to US physical therapists) which presently offer direct access to physical therapists. The success speaks for itself. The Military offers physical therapists unprecedented freedom to practice; therefore, there is no reason to believe that offering such to the general population would result in any differing outcomes. Insurance companies need to be forced to pay for applied physical therapy procedures with or without a prescription; in the long term the insurance company will end up saving a lot of money. In time and with education, the insurance companies will realize, not only the medical benefit of patient's seeing a physical therapist initially, they will also note the financial benefits to themselves, as well as to the consumer.
Roy Matheson and Associates, Inc. seminar materials relate that, in general, it is not possible for a physician, using medical information alone, to make reliable predictions about the ability of an individual to perform tasks or to meet functional demands. A physician can determine, however, whether or not a particular medical condition has become permanent because it is static or well-stabilized. When it is stable, there is no medical reason to expect that the individual will gain or lose future functional ability. When functional ability is assessed by a standardized nonmedical procedure in a vocational rehabilitation facility or in an occupation setting, the physician may have confidence in the determination.
(to be continued)
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Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - June 23, 2000 7:35:00 PM
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wincon
Posts: 65
Joined: June 24, 1999
From: Somerdale, NJ USA
Status: offline
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The reference supplied for this information is from "Guides to the Evaluation of Permanent Impairment: 2nd Edition"; American Medical Association.
Last, but of course not least, the simple fact that Chiropractors have Direct Access is perhaps one of the most compelling reasons to avail physical therapists Direct Access. I have a publication which clearly delineates this and for which I would be happy to furnish upon request.
I am in the process of gradually weaning myself from the field of physical therapy. I cannot practice in a field which is controlled by those who are not of my field. I am tired of trying to find diplomatic ways to tell physicians that the patient has reached a plateau and should be discharged or that their problem isn't from their shoulder it's form their neck or not from their hip but from their back, etc.., etc.. I am tired of being tied up and prevented from doing what I know is right. I need to evaluate and treat as I have been trained. My conscious prevents me from tolerating a field which is becoming more of a joke day by day under the current system of things. I want to indicated and prove that a patient is magnifying their symptoms if they are magnifying and not told to simply indicate only what the doctor requests from you. I want to prove that a patient is unlikely magnifying if this should be the case. I want to treat with what I know is best for a patient and avoid the HUMER's treatments so prevalent on doctors prescriptions, out of shear ignorance or out of the desire to earn big money to recoup for losses incurred relative to changing medical service reimbursements. I want to be able to tell a patient to his/her face that 'I don't think their symptoms are coming from their spine, I think they are coming from their knee as none of my tests can reproduce their symptoms when stressing the spine, despite the diagnostic reports (recall such reports are not necessarily indicative of patient's problems). I don't want to fear having to contradict the physician and losing my job.
I want to function in my own field in my own clinic and I want insurance companies to reimburse me properly for services rendered. In the end, the insurance company will save money, medical costs will decrease, the medical/healthcare consumer will safe money, the safety by which patient's receive their care will improve, patient's will be educated in self treatment methods to help prevent recurrences. I know what Real Physical Therapy consists of, I want and need to opportunity to provide Real Physical Therapy and unless Direct Access becomes a reality, I and my colleagues, will not have that opportunity. You will see an enormous difference in the care given, this you can be assured. Tests for symptom magnification will be standard practice, patient will receive the appropriate treatments they need and when they reach a plateau they will be discharged. If patient's reveal a sinister history, they will be referred out to the appropriate source, whether that be a medical doctor or referred out of specialized diagnostic studies. Physical therapists can relieve the volume at physician offices and allow everyone to provide better care overall. If you examine every area in the world that allows direct access for physical therapists, you will see 'It Works!" We also have to ensure that Insurance companies are not allowed to required a physician referral in and endeavor to avoid paying for physical therapy visits. They too need to be educated in how they will also benefit in the long run as patient's will be discharged sooner and with much more complete home programs focused on prevention.
Best Regards,
Mitch Hackerman, PT, Cert. MDT, CMT, NMT, CFT
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RE: Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - October 16, 2007 10:46:54 AM
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TLB
Posts: 353
Joined: September 13, 2002
From: Arizona
Status: offline
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Cliff notes please!
Just kidding, I read most of it and agree 100% but you're spitting in the wind. IMO nothing changes until we go cash pay only, then and only then will we have true direct access and the middle of the road PT will be put out to pasture.
< Message edited by TLB -- October 16, 2007 10:52:30 AM >
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RE: Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - October 16, 2007 2:51:22 PM
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Dr.Wagner
Posts: 1242
Joined: January 24, 2003
From: Indianapolis
Status: offline
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True or False:
You need to learn to Edit...TRUE!!
True or False: You are likely a student attempting to prove a point...true
True or False: You are very adept at "Cut and Paste" features on your computer ...True
True or False: You have no idea what Osteopathic Medicine is except you read about them in your chapter on "Cranial Sacral Therapy"...True
True or False: You are angry and resentful at the way Physicians have treated PT's...or at least that is what your instructor has said...True
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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RE: Re: DIRECT ACCESS FOR PHYSICAL THERAPISTS - October 17, 2007 9:31:14 PM
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Dr.Wagner
Posts: 1242
Joined: January 24, 2003
From: Indianapolis
Status: offline
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Sorry for the bit of anger that I responded with, but when there a "them vs us" mentality, it becomes harmful. No one is an island...there is no "them"...the real problem is NOT direct access, but fair payment by insurers. The original poster spoke in generalities and I took offense.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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