would you if you could

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FLAOrthoPT -> would you if you could (April 11, 2007 2:46:00 AM)
If there was a service that came to your office say once a week or every other week that would do diagnostic services for you (for the time being ignore the question of who writes the orders etc) specifically NCV testing and VNG vestibular testing that would help with differential diagnosis of any sort of cervical, brachial plexus, cubital, carpal tunnel, or radiculopathy, low back or sacral radiculopathy, diabetic or non-diabetic neuropathy, tarsal tunnel, sciatica, etc....and be able to help shape your treatment when you discover peripheral vestibular vs. central lesion for balance problems...with no cost to the patient, no cost to your clinic.... would you be interested in this service? and do you think it would make the referring physician mad if you ran tests to help your diagnosis? even if you included them in your decision making? just throwing out some ideas, curious to what you all think.... ben

orthotherapist -> Re: would you if you could (April 11, 2007 3:12:00 AM)
Anything that may be available to assist you with treating your patients to the best of your ability would of course be beneficial... That stated my lone economics class (in high school) drilled us that there is no such thing as a free lunch - so who is "paying" for this in the end. The referring physician should not be mad if you keep them in the loop if it is ini the best interest of the patient. But physicians are physicians so some may feel like you are going behind their back and taking some of "their territory"

PTupdate.com -> Re: would you if you could (April 11, 2007 3:57:00 AM)
But, just because someone presents with a problematic EMG/NCV does not mean they are symptomatic for that particular problem. Their pain /issue could be completely different in cause. No different than "well, your MRI shows a bulging disc, so that's why you have back pain" John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

FLAOrthoPT -> Re: would you if you could (April 11, 2007 4:05:00 AM)
But Duffy, isn't that why we pride ourselves in our clinical exam? Wouldn't you love to know if you had radial nerve entrap or just a bad case of tennis elbow? Lumbar radic causing foot numbness or is it just diabetic neuropathy? I agree diagnostics in themselves are not even half a picture, but with our knowledge of diff diag, wouldn't these NCV help confirm our suspicions or steer our treatment? as far as "Free lunch" it will be paid by insurance, so of course no free lunch, but that is not the question I am posing. Basically posing the question of if we had access to diff diag tests would it help shape our treatment, if these 2 tests were available to you, would you use them? if they did not cost the patient any extra money, would you order them?

USAPT -> Re: would you if you could (April 11, 2007 4:47:00 AM)
It would be enlightening to confirm my clinical exam if I suspected HNP/facet radiculopathy, lateral foraminal or central spine stenosis, adherent nerve root, etc. (i.e., eval & suspect the diagnosis--->treat them (centralize or peripheralize sx)--->confirm or deny with imaging. Ben, your idea is in tune with the fact that some of us are already employing the use of diag US to exam multifidus/TA, etc. I would think about it if my v/day would justify paying for the individual who was administering the test.

FLAOrthoPT -> Re: would you if you could (April 11, 2007 4:51:00 AM)
this would all be at no cost to you, would be done by an external company. I am doing it on a small scale down here in physicians offices, but thinking about moving into PT clinics..

Dr.Wagner -> Re: would you if you could (April 11, 2007 7:56:00 AM)
I think what you are REALLY speaking of is the patented "******** 3000: Advanced Crap-o-meter" a machine that can tell if a patient is perhaps embellishing a bit TOOOOOO much (ie see workers comp, car accident, chronic pain, etc etc)

FLAOrthoPT -> Re: would you if you could (April 11, 2007 8:13:00 AM)
lol, no not quite, though it would be nice on those pts!

Rwantz -> Re: would you if you could (April 11, 2007 2:03:00 PM)
I am not sure who is paying for this service, although it is a great concept. Yes, who would authorize the testing. Differential diagnosis does not mean that the person treating has to run the tests to differentiate. I see legal problems with it, however, if it was available just for the fun of it then why not. I have worked in a clinic that has their own NCV set up and they perform them in the clinic. I can't say that they are done well, but they are done (with appropriate authorization to my knowledge).

ginger -> Re: would you if you could (April 11, 2007 2:05:00 PM)
Does it go 'PING'?

Shill -> Re: would you if you could (April 12, 2007 2:52:00 AM)
Ahh yes, the machine that goes "ping". From the land of silly walks, I suppose. I dont know that this would be consistently all that helpful. How often do we really have an accurate diagnosis, and what percent accuracy do you think we might have in those cases? Studies on tissue of origin dont paint such a rosy picture, as there is always differential. Not to mention that certain theories of treatment are based on a diagnosis that is completely unobjectifiable (invented word) through expensive devices. (Specifically, lets say adverse neural tension/mechanical tissue strain, and even radiculopathy without frank nerve root compression, and therefore no conduction changes) what costly test would confirm these?

FLAOrthoPT -> Re: would you if you could (April 12, 2007 4:18:00 AM)
I love the skepticism. So basically you're saying, yo would never want access to order diagnostic tests because you are always 100% certain of the differential when you clinically diagnose. I am very confident in my clinical diagnosis, but a diagnostic test would be a nice confirmation of the tissue of origin. It would be like saying you would never want a needle full of novacaine to inject into an area you tink is responsible for the pain to rule it out. if you take any of the IAOM courses based of cyriax, they often allude to not only treating the dysfunction, but figuring out the origin of the tissue as well, they usually do it with selective needling though. Just was throwing this out there, so keep up the answers, I am curious to see what you all think.

orthotherapist -> Re: would you if you could (April 12, 2007 4:54:00 AM)
I think you stated the exact reason there is skepticism ; if you are very confident in your clinical diagnosis and the diagnostic test would be a "nice confirmation" it sounds to me like the test is done so that you may pat yourself on the back when you are correct about the clinical diagnosis. I am not saying there are not times to use it but to confirm what you already are confident in does not seem to me to be a good use of health care resources even if it is at no cost to patients (which it is because they pay the insurance which pays for the test). If you asked yourself "would I potentially treat this patient differently if I had more diagnostic tests run" and the answer is yes then by all means it would be appropropriate to complete the diagnostics - all too often in medicine tests are run without using clinical reasoning/evidence. This is either to make $$, protect your back (defensive medicine), or because it has always been done that way. Off my soapbox - have a great day

ginger -> Re: would you if you could (April 12, 2007 11:31:00 AM)
Agree with Shill wholeheartedlyandthensum ( not a made up word ), what are we ? we are physiotherapists. Trained to observe and be sensitive to movement dynamics. Good , possibly great at using our hands and physical senses to discover what is relevant. Surely we don't need/want to enter the lopsided world of the medical merrygoround ( this one is made up , but good ), where more and more machines are used in order to convey the useless to the equally unable. Get a grip.

ianwvu -> Re: would you if you could (April 12, 2007 8:02:00 PM)
The more info the better, I say its a good idea.

Sebastian Asselbergs -> Re: would you if you could (April 13, 2007 12:36:00 AM)
Why would one need even more information? Since when is the tissue of origin even a problem for a well-trained PT? Does the "extra" information profoundly affect the treatment choices? If you think they do, then by all means - get on board..... I am with shill and ortho and ginger - overkill...

PTupdate.com -> Re: would you if you could (April 13, 2007 2:13:00 AM)
Hi Ben: The issue becomes clouded, as others have indicated, as to whether the true problem will even show up with an EMG/NCV study. A person with a suprascapular nerve injury will present with what looks like a completely torn rotator cuff, but lack of pain in the appropriate areas with testing usually keys one into the right diagnosis. The EMG testing done will be negative, at least for the first 2-4 weeks. Having the good fortune of a PT practicing next door that does nothing but these tests, the literature supports the fact that many people come up with problems on their test, but are asymptomatic. The tennis elbow patient you suggest may indeed show positive radial nerve problems on a test, but actually still have plain old tennis elbow. We would be inappropriately chaning our treatment based on a test, not on clinical skill and judgement. John Duffy, PT OCS [URL=http://www.PTupdate.com]www.PTupdate.com[/URL]

Shill -> Re: would you if you could (April 13, 2007 2:20:00 AM)
Ben The "never" and "100% certain" idea came from you. Youve read a bit too much into what has been said. That's too strong, in my opinion. The initial question posed paints a picture of an unreal world. If we ever do get to order tests, we will need judicious and appropriate use of these, not willy nilly, even silly use. I realize it was your intent to do this, but nevertheless... Very interesting and thought provoking topic and kudos to you for that.

nari -> Re: would you if you could (April 13, 2007 10:26:00 AM)
Again, why would one need even more information? (Sebastian) Doctors may need more precise diagnoses because they are dealing with different issues. We do not really want to follow blindly down the path of relying on some gadget to tell us what we should do. Once installed, this gadget would gradually erode what clinical skills we have, insiduously.... "I think it is a tennis elbow. but the machine says it is something else, so I must be wrong.." No way. Nari

FLAOrthoPT -> Re: would you if you could (April 13, 2007 11:31:00 AM)
but if we were in true direct access would we owe it to our patients to make sure our egos are in check?

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