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Why???
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Why??? - June 18, 2004 8:06:00 AM
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mcap56
Posts: 617
Joined: October 26, 2002
From: New York, NY
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Looking over these threads, I am tempted to ask a question........when working through a modalities class with my students or when teaching other techniques I ask them.....
"Isn't it a little depressing that we are having debates about things that were developed over 30 years ago??????"
I know modern medicine has stepped away from some of the old things that work, hands on care, thorough histories and careful physical exams...and we all know that we rely to much on complex technology.......
However, isn't it time for PT to step into the modern age? How and where are we integrating any technology into the clinic? What are we doing now that could not have been done 20 years ago?
What do you think?
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Re: Why??? - June 18, 2004 8:47:00 AM
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jma
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From: NY
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Hello,
Yes, I agree. The fact that we still debate on things, especially modalities or treatment, is that they have been around for so long but they have have not been found clinically effective. For example, the research on US had negative reviews but yet continue to be used. As far as techniques go, they have not been researched thoroughly. On top of this are new modalities (laser (cold) and techniques being used that have not been fully investigated yet as well. In other words, we are just adding to the list of things that we haven't proved or disproved its effectiveness in he clinical setting. We have a lot fo catching up to do in the meantime.
JMA
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Re: Why??? - June 18, 2004 8:58:00 AM
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Shill
Posts: 1092
Joined: February 13, 2003
From: Madison WI USA
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Mcap,
Great question. I have two opinions. One is that we should try to do more studies proving that what we currently do actually works, and we should dump those things that have been perpetuated througout the years ONLY based on traditions, not results.
Secondly, I agree that we need to step into the modern age, but what does that actually mean? I am on a committee that is supposed to come up with ways that our clinic can provide "state of the art care". We cant even really define state of the art care as of yet.
My definition of it is care that gets consistent, proven, research backed, results.
Things I'd like to see: Fluoroscopic evaluation of joint motion instead of plain films. (lots more radiation, but someone must be smart enough to figure out how to make the radiation equal)
Pain Scanner: Lights up in response to presence of inflammatory chemicals, nociceptive transmission, histamines, and all that other stuff.
Polygraph assisted evaluations and subjective interviews. To weed out secondary gainers.
I can see it now....."Does that hurt?" Yes it does...BEEEP! OK, no it doesnt.
_____________________________
Steve Hill PT
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Re: Why??? - June 18, 2004 9:22:00 AM
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PTPLUS
Posts: 50
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Well I think that most of the dispute over modalities is a moot point. The purpose of a modality is too:
1. Provide "optimum" environment for healing
2. Allow better compliance with an exercise program
3. Help decrease acute edema/pain, or help break a "pain cycle"
When taken in this context we have plenty of modalities at our disposal. The purpose of a modality is not to strengthen a quad, or rehab a lumbar problem, but to "help" in a rehab program. Once this was a big part of PT, but I think the progressive PT will focus the majority of treatment on "active" treatments such as exercise, HEP, and lifestyle modification.
I'll say this to add a little spice to the board:
Overuse/misuse of manual interventions is just as bad as overuse/misuse of modalities as it promotes dependence of the patient on the therapist for improvement instead of active interventions, which puts much of the responsibility for long-term outcomes on the patient. I think we've all seen the cowherd "shake and bake" clinic where you get 12 visits of passive treatments then ask the doctor for more. Recently I've heard PT's say well we're not modality driven we are "manual therapist" (usually while looking down his/her nose). Well, I'll stand up and say that until proven different one is not much different than the other in many cases.
Addendum: This post is in no way meant to dispute or discredit any of the obvious benefits that can be had with manual PT interventions. I do so only to bring up the point of the potential of abuse of another passive treatment.
Good Day!
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Re: Why??? - June 18, 2004 9:26:00 AM
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Alex Brenner PT MPT OCS
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From: Kentucky
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MCap,
I have tried to completely automate our PT clinic. Basically all new exams and progress notes are done electronically using a template created in Microsoft Word. The notes are all typed. It makes a nice product, easy to read and follow. I keep all of the notes in a secure database. I also send via secure connection in our clinic a copy of the new evaluation to the referring physician on the same day that I see the patient. I have received feedback from referring providers and they all seem to really like the system. Most actually READ the note because it is sent like an email attachment! We'll at they at least read the assessment and plan part of the note. I doubt they read my hx or goals. We all like to read email.
I also created an automated Oswestry questionnaire using Microsoft Access that all of my low back pain patients fill out at a computer terminal. We have a computer terminal in our clinic specifically for patient use. They sit at the terminal and complete an automated Oswestry that was constructed using Microsoft Access. The program automatically scores the Oswestry and places it in a database. I can access the database from my desk computer. It works really well and the database is an ongoing data collection point for me which I use for performance improvement projects. With just a little training with Microsoft Acess you can do some pretty cool stuff, like automating forms etc. I think this is one way we have moved into the modern age.
_____________________________
Alex Brenner, PT, MPT, OCS
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Re: Why??? - June 18, 2004 9:36:00 AM
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Dr. Perkins
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From: New York
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I agree that the technology involved with the actual practice of physical therapy has not changed much in the last 20 years.
There are some modalities available that were not in the past, like anodyne.
I think that where technology is assisting physical therapists is in the area of the knowledge base. The information gained from new technologies helps us decide what techniques to actually apply and when to apply them. For instance, functional MRI’s are being used to better understand the central pain response.
One thing that I would like to mention is that physical therapy practice acts are preventing physical therapists from using many new technologies. This is because so many of the new technologies that assist me in my chiropractic practice are related to diagnostics.
As you mentioned, a good history and thorough physical exam are extremely important. When the appropriate diagnostics tests are added you have a real winning combination. For instance, take a good history, perform the physical exam, develop a preliminary differential diagnoses, start a trial of care in the absence of red flags, re-evaluate the patient and then if things are not progressing as expected test the differentials with imaging, lab, another physical exam or other tests. Next evaluate the results and update the differential and continue the loop until the problem is solved or a referral is made.
The step that physical therapists are being left out of is develop the differential and then when needed test the differential with the new technologies that are now available. I see this as a real problem. The theory development and then testing and altering when needed is key to professional development and serves as a self evaluation and learning process in regards to skill in developing the correct initial diagnoses.
I don’t see the lack of technology, in the actual delivery of rehabilitation procedures to patients, as a problem.
I have to keep in mind that much of physical therapy is delivered in a team approach with the physical therapist providing the rehabilitation procedures and then communicating the results to a medical doctor. When things aren’t going right the two confer and the medical doctor happily tests the differential with further diagnostics and then the two confer and the care continues with an updated plan. (This is where I am supposed to insert a sarcastic remark about how this almost never happens in reality.)
I support physical therapists in there efforts to improve there practice acts, direct access may be a first step but there are some other problems that should be addressed so that physical therapists can more directly take advantage of the technologies that are available.
_____________________________
Aaron W. Perkins D.C., P.T., M.S.
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Re: Why??? - June 18, 2004 11:53:00 AM
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OAK
Posts: 184
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"Great question. I have two opinions. One is that we should try to do more studies proving that what we currently do actually works, and we should dump those things that have been perpetuated througout the years ONLY based on traditions, not results."
If someone is doing a treatment and they're not sure if it "actually works" maybe they shouldn't be doing that treatment in the first place!
Research should be done to prove what PTs already know - Physical Therapy is beneficial.
If you don't believe in what you are doing you are in the wrong profession.
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Re: Why??? - June 18, 2004 2:24:00 PM
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tr6454
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I used to use computerized exercise equipment that cost tens of thousands of dollars. I could generate enough data to make any grad student sweat. The most up to date rehab money could buy.
I now use it to store my stability balls on!
_____________________________
Terry
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Re: Why??? - June 18, 2004 6:03:00 PM
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PTupdate.com
Posts: 1474
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From: Pittsburgh, PA USA
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Very good question, mcap.
I think some new things have come out over the past 5-10 years...iontophoresis has been made easier with buffered electrodes and now prepackaged meds. Laser therapy, Anodyne and other similar products are being introduced (although not yet proven).
Perhaps there is really not much more to be developed, either modality-wise or even manual therapy wise.
New products may be developed, but probably not by PT's. The cost of something new and novel (compared to the "barbaric" simple method of electrical shocking that we all do) can be substantial, and most likely NOT absorbed by the PT community. Instead, it will be engineering and biotechnology firms that are looking for future profit.
Maybe our profession is like pizza. There is really no way to improve any more, as that has been done. Now, the shops that succeed are the ones with slightly better ingredients, service, and price. Just like us. The ones that succeed have just the right recipe for treatment programs, take real good care of their patients, and consider the financial costs to the patients.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Why??? - June 18, 2004 7:06:00 PM
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tucker
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From: Texas
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I have to jump in here. I would have agreed with you six year ago John, but this is fortunately incorrect. Did you know the US Patent and Trademark Office announced that there were no more ideas to be patented...and that was back in the early 1900s!
I am sure there are several simple and complex ideas out there that will come from PTs. Let's see...Gary Gray, PT invented the BAPS board while using some plywood on tennis balls. Just recently, Lesle Bell, PT invented a new bra for patients with lymphedema and won several awards for the device. These are simple ideas.
I say this as I am preparing to travel for a final prototype design meeting. I had a simple idea five years ago, made a concept, patented it, and finally found a large rehab manufacturer to develope it. With the assistance of some amazing engineers, it will be on the market next year.
Trust me...It can happen and therapists are the ones that can start it. Yeah, we will need help from engineers, but it has to start with that single idea. I encourage all therapists to explore any ideas that may help other patients. It takes persistence, but it is extremely rewarding!
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Re: Why??? - June 20, 2004 12:44:00 PM
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mcap56
Posts: 617
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From: New York, NY
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It's great when therapists can apply for patents and develop products. Congratulations Tucker. I have had some ideas before but always got stuck during the protypes.
However, the thread is about technology integrated into practice. It isn't necessary that we invent the technology. Technology advances all the time with or without us. How much of it are we bringing into the clinic??
Mcap
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Re: Why??? - June 21, 2004 4:28:00 AM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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Tucker,
I look at both of your examples and see someone improving on a previous idea. The BAPS is an improvement over a simple wobble board, which has been around for quite a while. The lymphedema bra is an improvement over the regular bra, again something that has been around a while.
There will always be enhancements to current ideas, which is great. However, there are probably a few novel ideas that have yet to be discovered.
One area that, while not new within nature but new to PT and rehab is the idea of drum therapy and drum circles. The results I have read about are truly amazing, yet so very simple.
John Duffy, PT OCS
[URL=http://www.PTupdate.com]www.PTupdate.com[/URL]
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Why??? - June 21, 2004 8:03:00 AM
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SJBird55
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Joined: May 10, 2004
From: Michigan
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Why don't we as physical therapists use diagnostic ultrasound? I remember about 13 years ago some guy coming in to the clinic and demonstrating the use of diagnostic ultrasound - and I remember we used it on someone's shoulder to see the rotator cuff tendons. Is that particular tool not sensitive or specific enough to analyze superficial anatomical structures? I haven't seen one since, but did think that with some training it could be an interesting tool to use to observe structures and observe potential changes in structures.
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Re: Why??? - June 21, 2004 8:28:00 AM
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Shill
Posts: 1092
Joined: February 13, 2003
From: Madison WI USA
Status: online
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OAK,
When I said we, I meant anyone who is a PT, not necessarily just me.
I believe in what I do. I dont believe in what I have seen some others in my field do. If a PT advertises that they do things like healing touch, craniosacral, and garbage like that, it affects us all my tree like friend. My take on our field, and its insecurities regarding credibility, is that adding a "D" to our degree wont add up to much, if our practitioners are still looking to manipulate someone's chakras.
_____________________________
Steve Hill PT
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Re: Why??? - June 21, 2004 8:33:00 AM
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Diane
Posts: 1506
Joined: March 9, 2001
From: Vancouver, B.C., Canada
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Hi SJ,
A PT in town here, uses diagnostic ultrasound to view/provide visual feedback to people of
1. SI joints
2. abdominal layers (especially TrA)
So I doubt it is out of reach. Probably handy for someone (like her) who is compiling a body of information from which she draws to write her books/articles/conference lectures..
For ordinary clinicians though, probably 'just plain old' kinesthetic feedback is more useful(transferable to patient as a skill set) and definitely cheaper on a cost percapita basis! (no capital outlay)
Diane
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Re: Why??? - June 21, 2004 6:14:00 PM
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PTupdate.com
Posts: 1474
Joined: October 8, 2001
From: Pittsburgh, PA USA
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SJ,
There is a diagnostic practice up the street from me, with an US for sale. I have waffled for a while about buying this (they only want $500) and playing around. I have read numerous studies and found that with proficiency, one can view changes in the patellar tenodn, Achilles tendon, MCL of the elbow, TrA, plantar fascia, and much more.
While I could probably not get reimbursed for this, the local orthos would most likely enjoy the extra diagnostic tool. Check with local diagnostic practices, especially those associated with OBGYN and see if they have something older just collecting dust. A nice dinner gift certificate for the tech would probably buy you some one-on-one instruction.
Duffy
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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Re: Why??? - June 21, 2004 7:07:00 PM
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goodlooks58
Posts: 425
Joined: October 21, 2002
From: CA
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All the new ideas are well and good and believe me they give good tools to PTs in doing their work efficiently. However, my concern is that Chattanoogas and Dynatronics and several other corporations are so good at marketing to gullible PTs that they know that PTs will buy equipment as long as it "helps the patient". There is still not enough evidence that all the modalities we use does what it is supposed to.
For e.g. The new Laser light equipment. The pricing is upto $14000.00. Now my question is: Where is the proof that it really works. If someone will show me the proof, I will buy it and alo convince the insurance companies who are paying for it. Some big name PTs are busy selling this Laser thing and gullible PTs will buy it as the selling is so good. I would like to use Laser in my clinic and see the outcome on few of my worst patients and then I will buy.
Since a very long time in California, workers comp is not paying for heat/ice modality and ultrasound. Why? because PTs have not proven to the insurance companies and to Medicare that it works. It is high time PTs start becoming smart users of modalities and thinking in terms of evidence.
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Re: Why??? - June 21, 2004 9:26:00 PM
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hinchinbrookphysio
Posts: 12
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From: North Queensland, Australia
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Evidence based medicine! The holy grail of the new millenium. Yes it is time we moved towards evidence based treatment particularly with respect to modality use within physiotherapy. I would like to highlight an excellent publication put out by the Australian Acute Musculoskeletal Pain Guidelines Group (MO's, Chiropractic, Physiotherapy, Osteopaths, Anaethetists). It is a comprehensive lit review rating treatments for ACUTE (<3/12) pain only. It puts treatments into either 1)evidence of benefit 2)conflicting evidence 3)insufficient evidence. Very interesting reading and likely to generate significant debate. A good place to start when analysing evidence. Current to 2002 publications.
http://www.health.gov.au/nhmrc/publications/pdf/cp94.pdf
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Re: Why??? - June 21, 2004 9:41:00 PM
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Dr.Wagner
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From: Indianapolis
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Diagnostic ultrasound is EXTREMELY difficult to get reimbursement for...even for physicians. Typically it takes additional schooling or certification in diagnostic ultrasonography (US techs).
Unfortunately ultrasound is extremely operator dependent therefore with wide ranging sensitivity and specificty...furthermore, it is not conclusive. If your clinical exam leads you to believe it is impingement sydrome...do you really need an ultrasound PRIOR to the MRI or do you just need an MRI. My money is on "straight to MRI". Therefore, does it ADD much to the exam especially when it is so operator dependent. Likely not.
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: Why??? - June 21, 2004 9:53:00 PM
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Alex Brenner PT MPT OCS
Posts: 1057
Joined: February 29, 2004
From: Kentucky
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I know of a couple of locations in the military where diagnostic US is being used. It is used mainly though to observe the transverse abdominus muscle. The PT's that I know who use it, observe the TA during lumbar stabilization exercise programs. I have only seen it demonstrated but they seem to swear by it. It may be a good tool to use while working with some certain low back patients.
_____________________________
Alex Brenner, PT, MPT, OCS
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