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Re: Total motion release

 
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Re: Total motion release - August 16, 2006 8:52:00 AM   
Karie

 

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From: Wisconsin
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Sorry Junction 13, I just read your reply or I would have included you in my earlier response. I agree with eveything you said. I am in the new age, cannot be otherwise when you are an owner of a private practice and obtaining insurance contracts. I am glad you "think" before paying for a course. It is expensive. For me, I not only have the cost of the course and it's related expenses, but I also loose revenue because I am not in the clinic treating. So, I do have alot to "think" about before I take a course. The fact that it was on Saturday and Sunday helped a great deal, not as much loss of time from my office, etc. I have yet to see someone offer a course for free, please let me know who's doing that, I would like to review that list. I am not trying to be condescending, but let's get real. Eveything costs, and in the end the insurance companies, our patients, the medical community is held to costs all the time.
You mention Upledger, as a side note, check out Michigan Blue Cross and Blue Shield, the second largest insurer in the country. Craniosacral Therapy is specifically listed under the manual therapy codes for Physical Therapy.
As a side note, I am not charging my patients or the insurance company for "trying" the TMR techniques on my clients until I see measurable outcome in my clinic.
Thanks for your thoughts, and have a great day!

(in reply to garv3)
Post #: 81
Re: Total motion release - August 16, 2006 9:18:00 AM   
SJBird55

 

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From: Michigan
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Oh, Kari, Kari, Kari...

So, you took a course recently. You are just beginning to use the techniques with patients. You saw results with what I'd assume to be "normals" that took the course. You're assuming you'll get results with patients in the clinic. You are going to go ahead and attempt the techniques in the clinic. [QUOTE]For me, the proof is in the pudding...if I show consistent measureable outcomes in my patients with a high degree of success in response to objective goals and patient satisfaction with regards to their complaint, then I use it.[/QUOTE]Yet, you are indicating to Junction that you aren't charging the patients for that aspect of your treatment because you are "trying" the technique.

So...
1) Do you have outcome data from the last year or two to know your actual outcomes through the use of standardized outcome measures? Which standardized outcome measures did you use?
2) How are you going to determine during the "trying" period of utilizing the technique whether your outcomes are better? If you aren't charging for the technique, what is your process in data collection that would indicate that you did use the technique with the patient?
3) What have you determined to be the standard to set as to when you will begin charging the patients? In other words, what is your defined range of positive outcome? How have you defined a positive outcome? How long is your "trial" period before you begin charging patients?
4) What are your inclusion criteria on the patients that will receive the technique and how will those patients be compared to patients in the past with your previous outcome data that would be the same type of patient? Compare apples to apples kind of a thing.
5) Are you documenting the performance of the technique and the provision of the home exercise program? And, in that documentation, are you specifically indicating that the time spent during that time wasn't "skilled?"

Times are really changing in expectations. The days of just teaching a course because of marketing and passion are over. Professional accountability and responsibility lies on the presenter for that "proof in the pudding." Professional accountability and responsibility lies on the attendee - the attendee has a responsibility to critique and think before paying money for a course.

"Appreciation" is kind of a soft word in my mind. "Appreciation" is basically the lowest level of a skill or knowledge goal. I can appreciate that first time posters took time to post their views. I obviously do not have to agree with their views. Tom isn't the one that spurred the discussion completely - it was more the views/opinions of others that lead to the discussion. The issue of evidence and critical thinking isn't just a Tom issue or a total motion issue, it is a professional issue. Proud and Junction brought up some very valid points... and you know, I generally tend to side with common sense... the whole idea of "if it sounds too good to be true..."

Oh, and just because a third party payer reimburses for a technique does not equate to a technique being effective....

(in reply to garv3)
Post #: 82
Re: Total motion release - August 16, 2006 9:43:00 AM   
Karie

 

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Really SBJ, a third party payer will pay for "ineffective techniques." I thought the "new paradigm" from the discussion was that third party payers are requiring "evidence based methods," before paying.

If I see results in "trying" then those parameters you discuss will be worth my time setting up. You see, I don't just jump on a new technique and make it my standard practice of care.

First criteria, the patient is willing to try it, period.

I'll go from there....if I decide to continue using the techniques, then I'll set those into motion.
Billing, it would be a therapeutic exercise home exercise 1 or 2 unit charge one time. That's what this is, a home program that a patient can use to control his own pain management. That's what interests me if it works.
I do enjoy the conversation..SB...SB...SB

(in reply to garv3)
Post #: 83
Re: Total motion release - August 16, 2006 10:37:00 AM   
SJBird55

 

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Umm, Kari, SJ will do fine.

I believe that third party payers do currently pay for ineffective procedures, yes. Ultrasound is a payable diagnosis code. There hasn't been anything in the system that, for example, ultrasound would only be paid if performed on calcific tendonitis of the shoulder. Treatments that are more passive in nature, such as ultrasound, hot packs and electrical stimulation tend to have poorer or even negative outcomes based on outcome data that I have seen, in particular with the Ohio Project. Yes, the codes for those procedures are payable. CMS is recommending the use of standardized outcome measures to be utilized to capture changes.... the future can go two ways... third party payers can get more specific in when procedures will be paid based on ICD-9 codes which is already happening in my state with both BCBSM AND Medicare OR third party payers can begin to require proof of improvement via the use of standardized outcome measures and change greater than the minimally clinically important difference established for the standardized outcome measure used. We are only in the present but the move is toward the future and toward non-payment for methods not established in evidence-based practice.

Without collecting data, utilizing standardized outcome measures and crunching numbers, you won't really and truly know your results. You're actually going about it in a backward way... take the time to set up and measure and then decide if results are occurring. Granted, since you didn't answer my questions regarding your current outcomes, that means you technically don't know your current outcomes which means that you really won't be able to measure the changes this continuing education course has had on your outcomes.

WHOA... sounds like you ARE billing if you are charging 1-2 units of therapeutic exercise. Technically, you ARE billing for an unproven procedure.

Yes, definitely a good discussion.

(in reply to garv3)
Post #: 84
Re: Total motion release - August 16, 2006 11:16:00 AM   
Karie

 

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From: Wisconsin
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SJBird55
Nope, not charging, you asked what I would be charging. Yes, I do have outcome measures and my present success rate is 95% and I have generally a month waiting list for new patients, but that's not the point is it? What are yours since you seem to have a "better" parameter than what I have, sorry about the SJ, SB, typing fast between patients is difficult sometimes.....
Have great day!
PS I don't use ultrasound or other modalities, I am strictly manual and exercise.

(in reply to garv3)
Post #: 85
Re: Total motion release - August 16, 2006 11:21:00 AM   
proud

 

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Junction13,

An extemely well done response to Garefoot. I would argue that the era of disregard for basic scientific principles has actually lead our profession down a path which maintains us in low regard among our medically credable pers.

There is no need for that. Physiotherapy when performed properly and in the context of what we can...and cannot do, is an extrodanary profession.

The new breed of academically minded PT will move us leaps and bounds over our past.

To the TMR group. Keep up the good work. Innovation is a wonderful thing. My problem here is exactly what tom stated himself. "cart before the horse". Today's PT should value and more importantly, respect the EBM model. Not because you love it, but because it will soon no longer be a "buzzword", but rather a prerequisite to billing and practice.

As for Toms one legged standing example. A wonderful little neuro trick. Another one is to locate an individual with cervical spine range of motion loss into rotation(adaptive shortening?)...then clank a tuning fork beside the ear opposite to the ROM loss...then re-test. Presto a temorary marked improvement in that ROM...

The tuning fork example is a great little trick not readily explained, but also has zero clinical application(as far as I know). Perhaps vestibular patheways are involved? Can we reorganize those pathways? That is for research to figure out. But for now...I am not clanking any tuning forks.

(in reply to garv3)
Post #: 86
Re: Total motion release - August 16, 2006 11:52:00 AM   
SJBird55

 

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Karie, a broad generalization of 95% success rate doesn't seem realistic. You measured what with what population to have a 95% success rate? If you had that great of a success rate, what motivated you to go to a course that seemed to indicate a 98% success rate? Why pay for a 3% difference when it sounds as though you were already doing fine?

I use the PF-10, DASH, ODI, NDI and LEFS with all the appropriate patients. I just had 2 years worth of data analyzed. When you analyze your own data, it takes time to get a big enough of an n value to have any meaning. To respond to your question of outcomes will be difficult because patients were categorized via The Guide and I purposefully also defined each patient's discharge reason. I don't view my results in the terms of success rate - I specifically look at change in outcome scores and the effect size. I'm into a year of another set of data collection because I'm interested in seeing if my outcomes have improved with low back patients. The rationale is that I learned some manipulation techniques and I know the clinical prediction rule... I'm under the belief that my outcomes should be better. (Less disability at discharge and less treatment visits over the same duration of time.) I'll know in another year or so when I again have enough data to analyze if my outcomes are better. Through the process of analyzing my outcomes, I believe that change of score and effect size are not good enough numbers to use to prove there was an effect. Somehow, I need to incorporate the minimal clinically important difference to truly assess positive or negative outcomes. Effect sizes are statistically driven and I'm not necessarily sold that even though my effect sizes tend to be 1.0 or greater that that effect size is necessarily clinically relevant without considering the minimally clinically important difference. I can't give you my success rate, but I know my past performance on change in outcome scores and effect size. As you, I utilize very modalities infrequently. I don't even have an ultrasound machine in my clinic... nor do I have an electrical stimulation machine. I do have a phoressor, but I believe I've only used it on 2 or 3 patients over the last year.

Proud, I'm kind of with you. I think it is great that ideas are being generated. I just hate seeing huge claims without any documentation to support those claims, combined with the lack of desire of those generating the ideas to do some research and be critical of their own beliefs/practices.

(in reply to garv3)
Post #: 87
Re: Total motion release - August 16, 2006 12:12:00 PM   
yarringtonpt

 

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From: Waynesville, NC
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SJ,

TMR is based on therapeutic exercise principles and movements. And as many have pointed out with citing Bobath etc. there are aspects of neurore-education and therefore could easily be coded as such. I may be misinterpreting you and others because I feel as though you view TMR as something along the lines of craniosacral therapy. It just isn't so. I don't believe that each of does a thorough leterature search and case study before, during, and after each patient. We go off of the body of research we have read, studied, and observed.

Today, I had a patient with severe tightness in his left quadratus lumborum. I had him do a stretch to "lengthen" his short side in standing. I have never read about this technique. I also did a few other quad lumborum stretches, based on anatomy, that I have never seen in published literature. Was this wrong?
I did not wave crystals over his hip and back and chant. We did not sit and pray to Zeus for it to rleax and lengthen. Forgive the sarcasm, but my point is that we use our knowledge of kinematics, anatomy, etc. everyday with therapeutic movement patterns. Help me out, does this fall outside the realm of practicing evidence based medicine? Is this unethical? Does this illustrate a lack of professional accountability. If so, I'd love to hear and learn more about your practice patterns.

Eric

_____________________________

Eric Yarrington, PT, MPT, OCS

(in reply to garv3)
Post #: 88
Re: Total motion release - August 16, 2006 12:45:00 PM   
Karie

 

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From: Wisconsin
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Excellent SJBird, very good questions.

I went because I am required to take CEU's in my state, and in the years of practice, I have already taken alot and am always interested in new wheel developments because of my "thinking outside the box" frame of reference I have come to in my paradigm of experience.

I treat pediatrics to geriatrics and all kinds of diagnoses. Chronic pain or chronic disease states probably come up more often, but it changes.

Thanks for the info on your parameters, can you give me your references/books that you utilize, sounds more complex than what I utilize. But, as I said I am always interested in new ways of defining the wheel.

By the way what is your practice setting and how long have you been a therapist, just wondering it helps to speak to your frame of reference better.

:-)

(in reply to garv3)
Post #: 89
Re: Total motion release - August 16, 2006 12:51:00 PM   
yarringtonpt

 

Posts: 112
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From: Waynesville, NC
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SJ / Others:

I am very interested in implementing outcomes measurement and EBP in my clinic. Do you have any suggestions on getting started? Where can I best obtain outcomes questionairres, software, etc. I am gald that I stumbled upon this site. Much luck to all and I look forward to continuing discussions and learning from all of you out there.

Eric

_____________________________

Eric Yarrington, PT, MPT, OCS

(in reply to garv3)
Post #: 90
Re: Total motion release - August 16, 2006 1:02:00 PM   
Karie

 

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From: Wisconsin
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Eric,

Your definately right, TMR is not anything like craniosacral therapy. I alluded to that in referencing a third party payer question that was being discussed.
Your response is right on...Tom's course is exactly that, and he says it at the start that his approach comes from combining other previous avenues of treatment techniques etc.
Your comment about the attacks on therapist credibility and ethics is right on.

(in reply to garv3)
Post #: 91
Re: Total motion release - August 16, 2006 3:56:00 PM   
proud

 

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SJbird55,

I gather you may need to switch from a 40w bulb to a 100w bulb to help you light the way...

Anyhow, here is to hoping this approach is researched and proves to be an effective, reliable tool. Until then my patients will just have to suffer.

I have spent way too much time on this topic. My wife is wondering where I have gone.

Good luck all.

(in reply to garv3)
Post #: 92
Re: Total motion release - August 17, 2006 12:50:00 PM   
MPT


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From: Syracuse, New York
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Eric.

Check out this site for some good outcome measurement tools.

http://moon.ouhsc.edu/dthompso/CDM/outcomes.htm

_____________________________

Where am I

(in reply to garv3)
Post #: 93
Re: Total motion release - August 17, 2006 12:55:00 PM   
yarringtonpt

 

Posts: 112
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From: Waynesville, NC
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Thanks AR15!

_____________________________

Eric Yarrington, PT, MPT, OCS

(in reply to garv3)
Post #: 94
Re: Total motion release - August 18, 2006 3:45:00 AM   
Randy Dixon

 

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http://www.workcover.vic.gov.au/vwa/home.nsf/pages/outcomes/

Might be interesting as well

(in reply to garv3)
Post #: 95
Re: Total motion release - August 18, 2006 5:30:00 AM   
nari

 

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From: Australia
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Randy,

That is a cool list. Where I work at present we, as a team, use DASS,Tampa (I like this one best),FABQ,SOPA and PCS (sometimes).
By the way, if anyone doesn't know, Victoria is in Oz. (Not BC)

Nari

(in reply to garv3)
Post #: 96
Re: Total motion release - August 18, 2006 6:51:00 AM   
Alex Brenner PT MPT OCS

 

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I think the thread over on the evidenceinmotion BLOG from back in July fits well here.

http://blog.evidenceinmotion.com/evidence/2006/07/how_do_you_know.html

_____________________________

Alex Brenner, PT, MPT, OCS

(in reply to garv3)
Post #: 97
Re: Total motion release - August 18, 2006 7:54:00 AM   
proud

 

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Alex,

Thank you for that! Unfortunatly my old university actually places these "gurus" in a position to teach the orthopeadic courses to the students!!

I have no problem with someone who has spent extensive time learning and has a great deal of knowledge to pass along. Some of these "guru's" are in fact very knowledgable and even up to date on the research. Some of them however have so much vested interest in maintaing their "guru" status that they actually hurt the education of the students they teach.

I just think the days of these gurus claiming that the students need to "develop their magical hands" are numbered.

I know some of the guru's in my area are actually using their knowledge in a useful manner. Yet others cling to the notion that they are somehow "special". I think it is a self esteem problem for them actually...

(in reply to garv3)
Post #: 98
Re: Total motion release - August 18, 2006 8:22:00 AM   
yarringtonpt

 

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proud:

I agree with your comments about gurus. I had a Grimsby trained therapist once tell the entire class that he could feel facet joint movment in the lumbar spine in a obese patient just as well as a slender one. Magic hands says it all. No doubt that our palpation skills and intuition develop over time, but melting, floating, release, etc? Must be saved for a few of the gifted gurus. And this, I feel, leads many students to believe that they cannot be successful in manual techniques. In my opinion, our profession relies to hevily on continuing education to provide technical skills.

Eric

_____________________________

Eric Yarrington, PT, MPT, OCS

(in reply to garv3)
Post #: 99
Re: Total motion release - August 18, 2006 8:40:00 AM   
Karie

 

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From: Wisconsin
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Sounds like the "gurus" and egos are alive and well in the EBM model as well after reading the "evidence in motion blog" It is so humbling how this person knows with absolute certainty the "right way" to do things, "God like approach" that he expounds he has the inside track to knowing. "magical hands" no there is no such thing...developing your right brain skills along side your left brain, that anyone can do if that's their way of practicing. It's not the only way to get results, as we all know. Lots of techniques get people better, and I am in agreement with the EBM idea that we need to understand why and get to the "basics" of what is working and not waste time with the ones that are "clouding" what we see and feel.
I do in fact appreciate the posts of outcome measures that people are using and was looking for that on the other thread that Eric started.

(in reply to garv3)
Post #: 100
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