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Re: PT Code of "Non-DC Referral"
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Re: PT Code of "Non-DC Referral" - February 18, 2004 8:57:00 AM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
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Scanner,
I was misunderstood. Language problem. Diane and Steve pretty much talked about what I meant. Self dependence is the key with chronic patients. If someone is self dependent and generally is in control of his situation then passive techniques might have some limited worth. If not, then giving him what ever passive treatment (not just manipulation) only perpetuates the problem.
“same patient same problem” means we are not doing something right.
How do you rehab. degenerative disc disease anyway? Some research shows dynamic stabilization has good results (also when compared to manual therapy). So yes exercise it away. BTW, I think that a lot of the success of dynamic stabilization has to do with the patient being in control and not relying on a person or drug to feel better.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 9:15:00 AM
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Jeep
Posts: 353
Joined: March 28, 2003
From: USA
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[QUOTE].
How do you rehab. degenerative disc disease anyway? . [/B][/QUOTE]
This is the core of my treatment for DJD and disc lesions(bulge,herniation,prolapse) [URL=http://coxtechnique.com/]http://coxtechnique.com/[/URL]
[This message has been edited by Jeep (edited February 18, 2004).]
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Re: PT Code of "Non-DC Referral" - February 18, 2004 9:41:00 AM
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OAK
Posts: 184
Joined: September 1, 2003
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It's ridiculous to suggest that spinal manipulations are addictive!
While it's true that after manipulation symptoms may return, this does not imply that the manipulation wasn't effective.
Symptoms persist because the stresses that caused the joint dysfuction are not removed. The client will work at their job where they're lifting all day, sitting all day etc. The "cure" would be for them to quit their job, but this is rarely feasible.
There is no better treatment for mechanical spine problems than manipulation.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 10:10:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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Here's a good one...
WHAT is being "maintained" with maintenance manipulation?
A serious question.
Scanner, Let me give you my perspective on the questions you posted.
You are right about the conditioned athlete with the chronic pain syndromes. There IS something that he or she is not doing right.
Patients who choose to not comply with a program, particularily one that has helped them relieve pain, should be discontinued from PT care. There is no quick fix magic button panacea.
Patients who can control their problems need to be held accountable for doing so.
-What about the patient who complies, does their exercises like a good little girl or boy, but still has disc degeneration and chronic pain?
I know that you know that the disc degeneration isnt going to change. The literature in reputable journals will show you that having DDD does not necessarily mean that one has to have pain. The patient in PT is taught management skills once there has been adequate time spent learning whether or not this patient will be able to get rid of the pain through proper therapeutic exercise routines, appropriate activity modification, and the like. These management skills teach the patient to have more good days than bad days through the aforementioned activity modifications, and other principles of arthritic managment.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 10:17:00 AM
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Scanner
Posts: 71
Joined: March 17, 2003
Status: offline
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[QUOTE]How do you rehab. degenerative disc disease anyway? [/QUOTE]
In short, you don't rehab. ddd. There is no cure for ddd.
But, I manage ddd this way:
1. See the patient for a little while and actually confirm my conclusion that the disc in question is the pain generator. Often, it is difficult to pinpoint the pain generator on the first visit without first trying different approaches. That is, you can have ddd in front of you on an x-ray but it may really not be causing the problem.
Clinical correlation is necessary.
2. If after seeing the pt. and developing a relationship and you are convinced it is the pain generator, recommend flexiblitity exercises. Demonstrate.
3. Attempt to stablize through manipulation and home exercise. Follow-up to stress compliance.
4. If patient is still episodic with pain presentation and affords some pain releif from manipulative procedures, then consider maintenance care with active care regimen. This usually suffices. However, patient may also elect to medicate in conjunction.
5. If the above fails, I consider more agressive protocols - lordosis reconstruction via tractioning. I consider this if the patient has failed more conservative measures and is now considering epidural injections or the like.
There is usually out of pocket costs with this though.
6. If number 5 fails, then refer onto pain management, PT, or another chiropractor.
That's it in a nutshell. Of course, I take things on a case by case basis. There is no cookbook approach to d.d.d.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 10:33:00 AM
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Scanner
Posts: 71
Joined: March 17, 2003
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Shill,
What are you maintaining? The answer is simple:
the results you have obtained before on the case in question.
You are maintaining MMI.
This could be any combination of
1. Pain (VAS or NPS)
2. Mobility, ROM
3. ADL's
You get the idea. Whatever outcomes you assigned to the case.
Here is something from my local Medicare carrier:
[QUOTE]
A patient’s condition is considered chronic when it is not expected to completely resolve (as in the case with an acute condition), but where the continued therapy can be expected to result in some functional improvement. Once the functional status has remained stable for a given condition, further manipulative treatment is considered maintenance therapy and is not covered. [/QUOTE]
Note that it is not covered does not mean it isn't valid. YOu could substitute Vioxx in for manipulative therapy and you end up with a logical coverage statement.
As far as the athlete not doing their exercises right and that's the eternal cause of their chronic pain is a little naive and simplistic in my opinion.
You end with what I call, "What am I doing wrong?" type of patients. These athletes come in after seeing the PT frustrated and blaming themselves for a condition they may have little control over or is simply idiopathic. I often have to console these poor saps that they ARE doing things right and to stop torturing themselves.
The "It's Your Fault that you hurt" Paradigm will only go so far.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 11:31:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
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Scanner
What is MMI?
Your Quote: "As far as the athlete not doing their exercises right and that's the eternal cause of their chronic pain is a little naive and simplistic in my opinion."
You are entitled to your opinion. We all are. I like to base my opinion on the available best evidence.
If you think said athletes have no biomechanical issues or training problems with intensity, frequency,and or duration, exercise form (again biomechanics), or inadequate rest, then you may want to forget treating these folks. We (our fields) have different schools of thought as to what creates problems. And apparently rehabilitation of DDD. We do rehab DDD. You apparently dont. DDD is not a life sentence for continual pain. It does need management (patient oriented), and it can be rehabilitated in some cases to a pain free state.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 11:59:00 AM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
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“There is no better treatment for mechanical spine problems than manipulation.” so far it has not been proven. but we’ll probably not go there.
mechanical spine problems do not equal pain. Pain is more complicated then that (as you well know). Chronic pain that is. Looking at any pain from a mechanical or tissue based perspective is looking at only a small part of the picture.
"It's Your Fault that you hurt" – if this is what we lead our patients to think then we have failed in our explanation or patient education. I think most of us know better and do our best not to convey this message to patients.
As for athletes – many of them abuse their body and they know it. Many of them have predisposing factors that cause pain or injury. Most of them are aware of this and it will not stop them and they will not change their routine. I think they should not if doing their sport is important enough. Yet it is our job to point out if they are doing something wrong and try to help them with the consequences. Personally, I’ve been there and was lucky in having a good PT. I played for few more years being aware of my limitations (not that it stopped me from playing as usual) and not getting frustrated with the occasional pain.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 12:35:00 PM
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Scanner
Posts: 71
Joined: March 17, 2003
Status: offline
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MMI = maximum medical improvement.
First of all, a respected colleague of mine has pointed out I am using the word mainteance wrong and he's right - I should be using the word supportive care, no matter what my local Medicare carrier uses.
Anyway, I was holding up a mirror to your profession when I said:
"The pain must be the patient's fault."
Of course, no PT would ever be so undiplomatic as to say that (I hope). But in essence, that is what you are saying - that the athlete is overtraining, his form is poor, or isn't resting enough.
I'm tellin' ya, and you can beleive me or not, that IT ISN'T ALWAYS THE PATIENT'S LIFESTYLE/FAULT.
Some thing are idiopathic. We just "don't know." Heck, I say that all day long and I must be one stupid doctor:
"I don't know, Mary."
Of course you can rehab. a ddd case sucessfully sometimes. Sometimes you can't though. That's when you elect to manage instead of rehab.
DC = Doctor of Chronic
Think about that the next time you judge us. We are seeing difficult chronic cases all day (not self-limiting ones as someone suggested).
PT's are probably best known as "rehabbers"
DC's are probably best known as "pain managers."
There's a place for each.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 3:46:00 PM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
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“But in essence, that is what you are saying”. No it isn’t. What I am saying has nothing to do with putting a fault it has everything to do with coping with a chronic condition.
PT's are probably best known as "rehabbers"
DC's are probably best known as "pain managers."
I won’t comment on what your profession is best known for, that’s not for me to do.
Yes we are “rehabbers” and being “pain managers” is a big part of that. I think division of the 2 is impossible.
I think we can all say we are seeing difficult chronic cases all day. I work with a generally young population and I see those cases all day. I don’t think we are judging (this is not the right word) based on the type of patients you get. Our division is centered on professional differences and concepts and of course good old politics.
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Re: PT Code of "Non-DC Referral" - February 18, 2004 4:52:00 PM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
Status: offline
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Scanner,
I am quite often more than willing to tell the patient that I dont know why they hurt. But I also let them know that according to the literature reviews, the pain generating source can be accurately identified only 20 % or less of the time. Then I tell them that most often, I dont need to know the tissue of origin. Neither do they. I happen to disagree quite firmly with nrl regarding her(?) thought mechanical pain is only a small part, I think it is a HUGE part, but thats another topic. Like you, I get to treat a great number of patients with back and neck problems, and quite honestly, I enjoy treating those who have failed other treatments, whatever they have been. The best part is showing them that they do in fact have control over their pain, can reduce or relieve it when present, and prevent it from returning, provided they become diligent with their role in the rehab process. When I see that light bulb go on above their heads, at the moment they realize that they know what they need to do to control or abolish the pain---It makes my day. Thats why I got into this line of work.
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Re: PT Code of "Non-DC Referral" - February 19, 2004 12:29:00 AM
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Jeep
Posts: 353
Joined: March 28, 2003
From: USA
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".... the time I have spent in asking chiropractors questions all I have gotten, besides no responses...."
Well check my post above-
It was asked:
"How do you rehab. degenerative disc disease anyway"
I posted a link detailing treatment technique, protocol, rehab etc. However, review of all subsequent posts leads me to believe no one has bothered to even look at it.
Do the people asking "questions" REALLY want "Answers"? I'm not so sure.
[This message has been edited by Jeep (edited February 19, 2004).]
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Re: PT Code of "Non-DC Referral" - February 19, 2004 1:18:00 AM
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nrl
Posts: 121
Joined: May 23, 2002
From: israel
Status: offline
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Jeep, give us some time to read.
I looked at some of the literature mentioned at the web site. A lot of stuff. Is there an EBP review of the technique or a meta-analysis that sums up the evidence. It will be easier.
I saw some papers and they were using pain scales for outcome measurements. Do they use any functional outcomes as well? What about control groups and long term results?
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Re: PT Code of "Non-DC Referral" - February 19, 2004 4:00:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
Status: offline
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Jeep,
I went to your link on the cox technique, and it does look like some useful research is being done. The comparison studies, that are apparently being done will be of benefit. One thing I find interesting about the findings so far is that
"Federally Funded Research has thus far proven the following about Cox® Flexion Distraction:
(1) Reduces intradiscal pressures -- (2) Increases intradiscal height -- (3) Increases foraminal size"
Lying down and sleeping also does all three of these things.
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Re: PT Code of "Non-DC Referral" - February 19, 2004 4:59:00 AM
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Jeep
Posts: 353
Joined: March 28, 2003
From: USA
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"Lying down and sleeping also does all three of these things."
Is that your "professional" instruction to these patients? (ie. go home and go to bed?)
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Re: PT Code of "Non-DC Referral" - February 19, 2004 7:50:00 AM
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Shill
Posts: 1096
Joined: February 13, 2003
From: Madison WI USA
Status: offline
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Jeep,
My point was that this approach claims that it does things to the tissues that can also be accomplished by getting off one's feet and lying down. It could be said that because there are similar occurences with both activities, that neither is superior. That was my point, "professionally".
Steve
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Re: PT Code of "Non-DC Referral" - February 19, 2004 8:07:00 AM
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Scanner
Posts: 71
Joined: March 17, 2003
Status: offline
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Alba,
The reason I did not respond to your post is because it sounded like a bait. Now that you have opened up a bit, I think we can have a conversation.
[QUOTE]
How do you know that your maintenance patients are not taking prescriptions or OTC's for their pain? [/QUOTE]
I am quite sure they are. They tell me.
[QUOTE]
I don't know how you can hold a mirror up to the physical therapy profession or any profession and then exclaim that said profession is blaming the entire case presentation on that of the person who presents with the situation. [/QUOTE]
If you read back through the posts, one poster was implying, if not directly saying that all root causes of chronic pain in the athlete can be identified to something he/she is doing sooner or later.
I was just rephrasing it another way and reflecting it back upon you.
Here is a quote from NRL:
[QUOTE] As for athletes – many of them abuse their body and they know it. Many of them have predisposing factors that cause pain or injury. Most of them are aware of this and it will not stop them and they will not change their routine. I think they should not if doing their sport is important enough. Yet it is our job to point out if they are doing something wrong and try to help them with the consequences. Personally, I’ve been there and was lucky in having a good PT. I played for few more years being aware of my limitations (not that it stopped me from playing as usual) and not getting frustrated with the occasional pain.
[/QUOTE]
Now, of course, he is disclaiming his statement with "many" and "mosts" but what I don't see is an out and out admission that sometimes chronic pain syndromes are idiopathic.
You seem to be caught up in pointing out the "error of your patient's ways." That's all.
[QUOTE] I am sure in your private practice that you have to point out the obvious and at least come up with working rationales as to what may be the causal relationship with some aspect of a patient's particular problem. [/QUOTE]
Sometimes. I am an okay diagnostician.
[QUOTE]
Being a former athlete I can tell you that coaches do this all the time and not just physical therapists. [/QUOTE]
I don't care what the coaches are doing really. You and I are the health professionals.
[QUOTE]Coaching is about coaching and coaches are constantly critical. [/QUOTE]
I agree here.
[QUOTE]
I guess I am curious as to where you are getting the impression that physical therapists are judging the chiropractic profession. [/QUOTE]
My colleagues have charged that there was a thread running over here "Never refer to a DC." Andrew Ball has charged in moments of anger at our forum - "You aren't a real doctor."
I thought I would come over here and explore your psychology some. . .
[QUOTE]If the physical therapy profession is critical of the chiropractic then that is the function of a healthy health care system not an act of judgement. [/QUOTE]
Yes, chiropractic must be the most healthiest health care system, then ;-).
[QUOTE]
Are all chiropractors this sensitive to criticism? [/QUOTE]
Probably. I think so.
Usually criticisms start like this:
"Well, I think you are good for like a neck crick or something but. . ." LOL. And then, from there, it gets more ridiculous.
[QUOTE] Of the time I have spent in asking chiropractors questions all I have gotten, besides no responses, are questions of intent or claims of being anti-chiropractic. [/QUOTE]
Well, hopefully, I have departed from that. . .
[This message has been edited by Scanner (edited February 19, 2004).]
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Re: PT Code of "Non-DC Referral" - February 19, 2004 11:12:00 AM
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Scanner
Posts: 71
Joined: March 17, 2003
Status: offline
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Alba,
[QUOTE]
Which brings me to my point of "what is the intent?" that chiropractors have. It appears that chiropractors are a paranoid bunch. [/QUOTE]
Perhaps.
[QUOTE]
I am under the impression that chiropractors do not have the clinical authority to advise a patient to discontinue any medication usage. [/QUOTE]
You didn't say anything about discontinuation of medication, OTC or prescription. You asked about knowledge of medication usage. Part of the history gathering process is inquiring about medication consumption.
[QUOTE]
I would agree with this. However, if you are attempting to suggest that some athletes cannot do a certain aspect it may mean that the athlete just cannot perform the task at hand. I would enjoy seeing a sprinter become a distance runner. It just isn't going to happen. A hockey player unable to shoot a free throw does not mean that the hockey player is a poor athlete it just means that his abilities and skills are not suited for basketball. [/QUOTE]
Alba, is there a communication gap here? I wasn't talking about cross-training. I was talking about identifying and treating chronic pain syndromes in the athlete.
And what I was suggesting to the forum is that certain athletes execute their form correctly, don't overtrain, rest adequately and STILL have chronic pain syndromes.
This forum is appearing to have a hard time dealing with this statement.
[QUOTE]
I don't know why everyone here thinks I am a physical therapist. I am not. [/QUOTE]
Ummmmm. Never good at trick questions.
Because it's a physical therapy forum maybe? I'm a DC but was up front about my background.
[QUOTE]
What is the percentage of cases of chronic pain that are idiopathic? And really, what cases/diagnoses/conditions are classified as idiopathic besides scoliosis? [/QUOTE]
I don't know.
See how comfortable I am with those words, LOL?
You have to have some experience as a health care provider for awhile but you learn all these diagnostic/exam tests in school and then you get out and see these patients and say, "What the hey? This doesn't match anythying." You assess for psychosocial issues and can find any reason for secondary gain. Finally, you have to lump their low back pain as idiopathic or a wastebasket diagnosis, ddd, which of course, is a cop-out a lot of times (thus why you call it a wastebasket diagnosis).
[QUOTE]
When there is a reason to point such out I believe it would be appropriate to point such out. I rely on the concept of things that are "Seen and unseen". [/QUOTE]
No one is disputing that.
[QUOTE]
And you are the person to confront the physical therapy over a situation such as this? [/QUOTE]
No, in no way am I representative of the profession. Maybe I'll get ambassador status sometime LOL.
[QUOTE]And because one person may not refer to a chiropractor means that the entire industry is at fault? [/QUOTE]
No, that's why I was exploring. I haven't made any conclusions yet.
[QUOTE]
And if Dr Ball has moments of anger and suggests that chiropractors are not real doctors, really, what is that go to do with anything? [/QUOTE]
I am wondering if PT's will be good integrators in the integrative program.
[QUOTE]
What is the basis for his criticism? Is it because that chiropractors do not function as a primary care physician? [/QUOTE]
From what I have listened to Andrew Ball, I beleive his reasons are many. But I don't speak for him.
[QUOTE] I wouldn't go to a chiropractor to get a cardiovascular exam knowing that there are no residencies in chiropractic and specializations where training is given in a hospital setting.
[/QUOTE]
Okay, you wouldn't.
[QUOTE]
What evidence is there that chiropractors function outside this model? [/QUOTE]
What model?
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