RE: Re: PTA's performing joint mobilizations (Full Version)

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GaPTA -> RE: Re: PTA's performing joint mobilizations (January 12, 2008 10:03:51 AM)

Thanks for the information.  The COMTA course is now off the list.  I appreciate your help.



PTupdate.com -> RE: Re: PTA's performing joint mobilizations (January 17, 2008 9:00:27 PM)

Here in PA, we really got the shaft from our state association.

PTA's, as of two years ago, cannot perform ANY mobilization, and most take it to mean soft tissue mobilziation as well.  The wording in the law is/was quite vague, so nobody I know feels comfortable if they are practicing within the law.  Clarifications have been asked for with little positive response.

I can teach a patient how to do a self patellar mobilization, but my PTA can't?  I teach people how to perform an inferior GH glide themselves, or on their injured spouse, and again the PTA can't

And the real kicker? I now have to do all the soft tissue work as well.  If the PTA does it, I have to call it "massage", and it gets billed 97124.  But, when I follow up with manual therapy or mobilization, using 97140, CCI edits will not permit both to be billed.  So, I have to do both (quite tiring in a high volume clinic), or not count one of the techniques, which strikes down my billable time using the 8 minute rules.

PTA programs in the state have been told that if they teach any mobilization techniques (they all used to), they are in violation of the law and the state practice act.

Go figure



Kaden -> RE: Re: PTA's performing joint mobilizations (January 17, 2008 9:35:37 PM)

Hey John,

Wow, no mobs at all.  What was the rationale behind that decision from the state association?  I can see limiting spinal mobs but you make a great point with the ability to teach your patients self mobs but the PTA can't mob.



jlharris -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 1:16:22 AM)

If mobs are allowed for a PTA, why limit spinal mobs?  Vertabrae are joints just like the elbow, shouler, knee, etc.  Nothing magical there.  Why do many of us (and not directing this at just you Kaden) feel the spine has to be seperated from the extremities in relationship to joint mobs?

IMO, we are just playing into the Chiro's argument that you have to have 4 years of philosophy and spinal mob (ahem, adjustment) trainng to be able to effectively and safely treat the spine.  Research shows this is false.

BTW, my opinion is that PTA's shouldn't do joint mobs.  It's one thing to teach a pt one mob in black in white (push this hard in this one direction for this amount of time).  It's another to give free reign to a PTA to decide grade, direction, frequency, and duration on a pt that is (hopefully) changing constantly to the mob and needs constant ASSESSMENT as to how to adjust type and grade of mob to optimize the outcomes. 

Ther ex, modalities, gait training all fine with me.  Once the hands become the tools for rehab, then I think the PT should be the one doing it.  Of course, that is just my severly biased opinion.



Kaden -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 1:24:53 AM)

Jason,

My take on spinal mobs for PTAs has always been that I feel there is a lot more potential for adverse effects.  True it is a joint just like the elbow but when vertebral artery dysfunction, UMN issues, and cauda equina issues enter the eqaution with spinal mobs there becomes potentially a lot more to asses/eval and I don't think PTA's have the background to do this. 

If I had to choose allow spinal mobs for PTA's I oversee or no mobs at all then I would choose no mobs at all.



jlharris -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 1:41:02 AM)

Good points.  Personally, I don't manipulate the neck.  Although, admittedly,  I really haven't come across a specific study that shows Grade 1-4 mobs are any safer then Grade 5 (manipulation) to the neck.

I regards to cauda equina, have you seen any published articles that this has actually occured d/t a lumbar manip?  I know it is a "potential" adverse affect.  I've read about SCI with thoracic spine manip with two pt's but one had a hx of breast cancer that had metastisized the spine (Lead Kettle anyone?) and the other had sever osteoporosis.  So, it was more poor decision making by the practicioner than the manip itself that was the problem.



PTupdate.com -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 10:25:14 AM)

Brings up some interesting points:

Are the skills of many PT's with regards to some of these techniques really that much better than a PTA?  As I look back on both my institutional education, and continuing ed as well, there was no provision testing done to determine if I really had the right force/knack/skill compared to anybody else.

I do let PTA's, or at least USED to, perform some mobilizations.  I had no issue with the frozen shoulder patient and inferior/posterior GH glides....I was always reassessing anyway, so doubt there was ever any instance of someone becoming "hypermobile"

I preferred to do many of the spinal mobilizations myself, especially the neck.  However, no issue with a PTA providing pain inhibition grade I oscillations to an acute back, or patellar mobilizations when the normal knee to compare was laying 6 inches away.  I'd bet there are quite a few PTA's with better manual skills than the PT's they work for.

While we all hear warnings and there are so many fears regarding treatment of the spine, I'd bet my gonads that far more patients are either "injured" or at least agitated by PTA's using exercises on patients than EVER occurred during mobilizations of joints.



Kaden -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 11:17:26 AM)

Good points everyone.

Jason, as far as your question regarding cauda equina, you are correct, and I don't think I have ever seen any article either on a manip producing this consequence.

I guess some of my takes on spinal mobs by PTA's I've worked with stems from many of them being taught in schools peripheral but not spinal mobs so I've stayed away from going there with my PTAs. 

Jason, on a side note, why don't you manipulate the cervical spine.  Not challenging this notion just wondering your rationale behind it or any others who manip peripheral, lumbar, TS but not CS chime in.



jlharris -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 12:11:14 PM)

Kaden,

No, it's a good question as to why.  Vetebral arteries are the number one reason.  There are documented cases of CVA and death directly related to Cx manipulations.  Also, work by Cleland and others shows we can achieve good pain relief and ROM gains in the C-spine with T-spine manipulation; which eliminates having to worry about the vetebral arteries.  Now, would I go my whole career manipulating the C-spine on a daily basis w/o causing a stroke?  I probably would, but someone is going to cause one, and I just don't want it to be me.

So, like I said, it's a professional preference, and there thruthfully isn't much evidence showing my Grade I-IV cervical mobs don't have the same probability.  But that's how I do it.



PTupdate.com -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 12:39:30 PM)

Agree with Jason.  Why beat your kid when there are bunch of other equally effective ways of disciplining him?

Just a few years ago, I was treating a life flight nurse who had TWO flights on one weekend due to strokes (assume vertebral artery injury) at chiro offices.  Perhaps out of the norm, but nobody's neck pain is so bad that I have to kill them for it.

I have heard stories/theories that trauma can occur to the artery during manipulation or other techniques, but not terribly severe.  A few weeks later, after clottiing and partial healing, a clot dislodges and the CVA occurs.  Nobody ever puts the two together due to the long time lapse.  Interesting thought



TexasOrtho -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 2:03:59 PM)

I couldn't agree more with John. I have seen very limited evidence supporting the regular use of cervical manipulation when there is a laundry list of very safe alternatives.  

I don't have the articles in front of me, but I do know there is evidence to suggest rotational manipulations to be substantially riskier than sidbending or traction manips.  Regardless, I've found mobilizations to be highly effective at restoring normal kinematics and don't feel the manipulations are worth the risk.

A well-trained PTA should be allowed to perform peripheral and spinal mobilizations.  It is the PT's responsibility to assess the skill of the PTA and outcome of the treatment.



Kaden -> RE: Re: PTA's performing joint mobilizations (January 18, 2008 2:30:00 PM)

I think when talking manipulation of CS you have to devide it into CV and mid/lower cervical.  I think there is much less risk when manipulating the lower cervical spine.  Most of the research describing VA problems with manips comes from upper cervical, usually a rotation manipulation.


Given the risk I don't think it should be the first line treatment but if a segment doesn't respond to multiple session of grade IV mobs then I think manipulation is appropriate.

I believe most PT manual therapy continuing education programs out there are teaching safer mobilizations compared to some of the typical chiropractic gross rotation manipulations (not saying all chiros do this - not trying to get into that battle). 

Mobilizations in the CS can be very safe esecially when using gliding techniques.  Simply put, these are advances of typical mobilization but with a HVLAT at the barrier.  No reason to employ a gross rotation moment and if sticking with anatomical/physiologic glides that thest joints typically perform can be done safely and with suprisingly little force and little amplitude to the rest of the spine. 

A lot of studies out there demonstrating some good manip techniques - here is a good one that I thought demonstrated some decent manips without significant long levers being applied.

Reid DA, Hing WA, and Monaghan M (2003): Masterclass,
Manipulation of the cervical spine, Manual Therapy 8 (1), 2-9



SMADAMS72 -> RE: Re: PTA's performing joint mobilizations (February 7, 2008 3:10:13 PM)

It is legal inthe state of Indiana.  I've had more Ed than most PTs and see patients that other PTs can't treat.  Let's look at the individual not the credential.  [8|]



jlharris -> RE: Re: PTA's performing joint mobilizations (February 7, 2008 4:11:57 PM)

quote:

I've had more Ed than most PTs


Wow, how do you make that claim?



Kaden -> RE: Re: PTA's performing joint mobilizations (February 7, 2008 7:27:44 PM)

More training in what? Joiint mobilization.  That may make you decent at mobing a joint and yes maybe even better than some PT's but thats not what is being argued here.  Performing a mob is one thing, evaluating a patient with a specific assessment and deciding what needs to be mobed is quite another.

You can't tell me you have more training than PT's in evaluating b/c as a PTA you are not allowed to do so.



TexasOrtho -> RE: Re: PTA's performing joint mobilizations (February 7, 2008 8:38:53 PM)

quote:

even better than some PT's but thats not what is being argued here. Performing a mob is one thing, evaluating a patient with a specific assessment and deciding


I believe he/she meant con-ed vs education.  The question was regarding PTA's performing joint mobilizations.  It is legal in many states, they are trained to do it, but each situation should be evaluated case by case.  I can't see much room for a grey area here.  If it's not legal in your state...don't break the law.  If it is allowed in your state, proceed according to your clinical judgement.



Sebastian Asselbergs -> RE: Re: PTA's performing joint mobilizations (February 8, 2008 9:51:43 AM)

quote:

ORIGINAL: SMADAMS72

It is legal inthe state of Indiana.  I've had more Ed than most PTs and see patients that other PTs can't treat.  Let's look at the individual not the credential.  [8|]


Well, here I have a problem.
Should I consider that farmer's wife who has such excellent hands? Or Charley, the silverback gorilla, who has throngs of females fawning over him, reputedly for his skilled use of the hands.....
Of course the credentials are essential - it is the first barrier that has to be crossed before one even talks about experience and personal skills.



Hitomi -> RE: Re: PTA's performing joint mobilizations (February 8, 2008 11:43:18 PM)

NC law is vague about PTA's performing peripheral mobs...basically acknowledging that they do them.  I have a question, probably directed to someone who is McKenzie certified.  Is "overpressure" during extensions considered a spinal mob?



annpsu25 -> RE: Re: PTA's performing joint mobilizations (March 9, 2008 4:28:58 PM)

I am also from PA. I'm currently a PTA student in my last semester.  We have had this discussion many times in class.  We too find it odd that PT's are able to send pts. home performing inf glides to their shoulder, and PTA's are not able to perform these.  We also discussed the PTA's that have been performing mobs for years, that are suddenly unable to do so.  From what I understand PTA's are still performing them, but are documenting it differently.



PTupdate.com -> RE: Re: PTA's performing joint mobilizations (March 10, 2008 7:47:24 AM)

Sure, one can perform a mobilization and call it a bunch of different things....capsular stretch, PROM, even neuromuscular re-ed (say, for an inferior GH glide to promote more normal glide during AROM).  But, everybody knows it's still considered a "mobilization", and nobody will be exonerated if/when something happens....the game of using semantics won't fly with some jury.  So, while the whole PA-thing sucks and has made my practice far more difficult, I don't plan on losing my license by permitting practice outside the law



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