What is helpful in a PT prescription?

[fozzy40]

Hello

I'm currently a physiatry resident and wanted to get everyone's opinion.

Physiatrists (as you may know) are trained in the medical diagnosis and treatment of a variety of neurological and musculoskeletal problems. I personally think that we perform the best physical exams among the medical specialties. Subsequently, we are taught from day one to be specific in our therapy prescriptions and not just write "evaluate and treat" as most physicians do.

Despite my efforts to write a good prescription, I suspect that it does not necessarily make a difference in to how physical therapists actually practice.

I always try to include:
- diagnosis with an idea of where is the problem (i.e. RTC impingement 2/2 scapular dyskinesis)
- weight bearing precautions
- ROM limitations
- where I think the source of the problem actually is
- directional preference when appropriate
- frequency and duration

In the realm of outpatient orthopedic injuries, is writing "evaluate and treat" all that most physical therapists need to know from physicians?

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[mtm34]

I have no problem receiving a specific pathology from a physiatrist/ortho/neurologist as long as the proper work up was done- either a cluster of diagnostic tests or some sort of imaging that is conclusive in diagnosing the pathology. Other wise I have no problem with XYZ pain 'eval and treat'. JessPT mentioned in another thread it is very helpful to include any underlying pathology info, in the outpatient clinics I have been in it is mostly up to the patient to provide the PT's with their PMH which health care providers know can either be too litte or too much information. Everything else you described is very helpful/often essential as well. The open relationship you are working at is what us new practitioners need to strive to create with one another. Good stuff fozzy.

 

[Fiveoboy11]

Great post, I'll post my opinions, but probably get grilled as usual, ha ha.

- diagnosis with an idea of where is the problem (i.e. RTC impingement 2/2 scapular dyskinesis)

A medical diagnosis is great, also consider that PT's go through an evaluation of the patient as well to confirm or refute possibilities. One may run into the problem where a diagnosis of RTC impingment translates to only treat the shoulder. When the actual problem leading to this may be somewhere else. I personally don't really look at a condition such as RTC impingement being secondary to only one thing (i.e. scapular dyskinesis), and this would be based upon a very thorough eval of the pt.

- weight bearing precautions

Yes please, and if it is PWB, please note a percentage.

- ROM limitations

Absolutely note ROM limitations (precautions), but PLEASE you do not have to say "work on PROM/AAROM." Just say what the precautions are.

- where I think the source of the problem actually is

You mean RTC impingement secondary to scapular dyskinesis? If it is that simple trust that the PT will figure this out and treat accordingly.

- directional preference when appropriate

The PT can figure this out

- frequency and duration

For the love of god leave this up to the PT. There are NUMEROUS issues that impact frequency and duration of treatment. Imagine someone sending you a script for PM&R that said 1x/mo x 6 months. Does that make sense?

In the realm of outpatient orthopedic injuries, is writing "evaluate and treat" all that most physical therapists need to know from physicians?"

As you've mentioned depending on the situation. Also consider that physician's sometimes write inappropriate interventions on a script they would like performed on a pt for PT, and over the years many PT's have learned to just do what the physician says. Physician's need to trust and respect PT's to provide what they think is best because they have the most knowledge in that area.

On a closing note, there is a great amount of variability in skill level of PT's. In order for PT's to become better as a group at treatment, they need to be afforded autonomy. This over the shoulder "supervision" of PT's does nothing for the patient, and in my opinion is actual detrimental to them.

Once again, only my opinions.

 

[fozzy40]

You mean RTC impingement secondary to scapular dyskinesis? If it is that simple trust that the PT will figure this out and treat accordingly.

I usually include this so that the PT has idea of what I saw on my exam.

- directional preference when appropriate

The PT can figure this out

I usually include this so that the PT knows what I was thinking on my examination.

For the love of god leave this up to the PT. There are NUMEROUS issues that impact frequency and duration of treatment. Imagine someone sending you a script for PM&R that said 1x/mo x 6 months. Does that make sense?

I understand what you are saying here. However, since I'm not yet officially practicing I'm not sure if there is a requirement from a coverage standpoint if we do have to document some sort of duration for approval purposes. But as you said, there are varying levels of practitioners. It can be frustrating from the physician perspective too when we see patients go for months of therapy and not getting better because of an inappropriate treatment plan. Then by the time we say them they are out of approved visits.

Physician's need to trust and respect PT's to provide what they think is best because they have the most knowledge in that area.

I understand that there is a "dynamic" between physicians and therapists. However, also trust that there are some physicians out there that do understand therapy principles and might have something to offer in the treatment plan as well. We aren't all bad so don't put us all in a box

Thanks for your input! I definitely appreciate it.

 

[Fiveoboy11]

Thanks for your response

I have a lot of respect for physician's, definitely appreciate their input whenever possible. I think the physician/therapist dynamic is a great great IDEA with potential, unfortunate for patient's is the fact that it really isn't a dynamic, in many cases not even close. Based upon my experience as a PT, it's more of a physician "ordering" physical therapy as if it is a medical procedure. Hopefully in the future, physician's such as yourself will see PT's more as clinicians who are specialists, doctors of physical therapy even. Because that is the reality. Imagine if a FM doctor referred a patient to you with specific instructions on treatment because he/she didn't like the outcomes the patient was getting from your intervention, or based upon his/her past dealings with PM&R doctors.

From the standpoint of patient's coming to physical therapy for numerous visits without benefit, I agree with you 100%. I see this a fair amount as well and it drives me crazy. Keep in mind how often physician's just tell patient's to stop coming to PT without even speaking to the PT about it. Consider these points: physical therapy does not always work on a patient with a problem that theoretically would improve with physical therapy. Here's something random I thought of - Dr: "you just need to work on your walking." Patient arrives for PT evaluation: "the doctor said I just need to work on my walking." PT: "we need to do x, y, z in order for you to get where you want to be." Patient: "the doctor said I just need to work on my walking." Script reads "PT 3x/wk x 4 wks, improve walking." Guess what, there are patient's who will walk up and down the driveway where they live and ignore the PT's HEP because of that one thing their physician said.

I would advocate for you to educate the patient on the medical diagnosis and say whatever you normally would as far as your medical practicing goes. HOWEVER, if you feel they need physical therapy, say something like "I think you need to see a physical therapist." Not "I think you need to see a physical therapist for strengthening." And from my perspective, not "you need physical therapy" because to me that minimizes the skill level of PT's and implies that you decide when someone needs PT, when in actuality it is a only a PT who knows when someone needs PT. Would you like it if you worked in a Inpatient rehab facility in a hospital, and a hospitalist sent you a consult, beforehand telling the patient they're staying for inpatient rehab. Wouldn't it be your decision on whether to admit them to your inpatient rehab program?


Sometimes, for various reasons, it just doesn't work. Even with the best evaluation, effort on the part of the PT, patient, and physician. And, in some cases PT's are being boneheaded and providing *****ic interventions (i.e. stim, US, heat), or manual/exercise treatments without a thorough evaluation, proper subjective information. Also, there are many many patient's who come to physical therapy just for the social aspect of it, without really needing it. They go to their physician, get a script, and come to PT because they like it there. Guess what, the PT is expected to see the patient for 3x/wk x 4wks. There is also A LOT of pressure from the practices PT's work in to see patient's for as long as possible. As a PT, you can get scolded for D/C'ing a patient early, especially earlier than the physician prescribed visits (legally the PT's duty), and if the patient isn't getting better, it will be implied that you're not doing the correct things.

I know physician's, especially PM&R know and understand the basis of physical therapy. But, if you are referring to a physical therapist you must trust they know more about treatment for the patient from that perspective than you do. PT does not equal PM&R and vice versa. Sorry for babbling on so much.

 

[fozzy40]

From the standpoint of patient's coming to physical therapy for numerous visits without benefit, I agree with you 100%. I see this a fair amount as well and it drives me crazy. Keep in mind how often physician's just tell patient's to stop coming to PT without even speaking to the PT about it. Consider these points: physical therapy does not always work on a patient with a problem that theoretically would improve with physical therapy. Here's something random I thought of - Dr: "you just need to work on your walking." Patient arrives for PT evaluation: "the doctor said I just need to work on my walking." PT: "we need to do x, y, z in order for you to get where you want to be." Patient: "the doctor said I just need to work on my walking." Script reads "PT 3x/wk x 4 wks, improve walking." Guess what, there are patient's who will walk up and down the driveway where they live and ignore the PT's HEP because of that one thing their physician said.

Patient perception of what we say (providers) is something we all have troubles shaping. No matter how or what I tell a patient, they will interpret it however they will. Patients will believe whoever they ultimately trust. I've had patients who won't do certain things because their PCP or orthopedic surgeon said something to the contrary. Believe it or not, I've also had patients insist on getting inappropriate testing at the mention/suggestion of their physical therapist. I do agree that most physicians probably have no idea what is done in physical therapy. At the same time, identfying the need for a PT evaluation is a small victory for uninformed physicians in it of itself. We always have to give "a reason" and perhaps that is what the physician in your example came up with.

I would advocate for you to educate the patient on the medical diagnosis and say whatever you normally would as far as your medical practicing goes. HOWEVER, if you feel they need physical therapy, say something like "I think you need to see a physical therapist." Not "I think you need to see a physical therapist for strengthening."

Most patients will need a reason when I order physical therapy. I don't think they would rest on "you need to see a physical therapist." I personally will give a functional goal to the patient as a reason.

Would you like it if you worked in a Inpatient rehab facility in a hospital, and a hospitalist sent you a consult, beforehand telling the patient they're staying for inpatient rehab. Wouldn't it be your decision on whether to admit them to your inpatient rehab program?

Haha...frustrating but it happens all the time.

There is also A LOT of pressure from the practices PT's work in to see patient's for as long as possible. As a PT, you can get scolded for D/C'ing a patient early, especially earlier than the physician prescribed visits (legally the PT's duty), and if the patient isn't getting better, it will be implied that you're not doing the correct things.

I understand that money drives most things in this world. However, this kind of pressure is what makes me leary of leaving duration of treatment completely unchecked. What do you mean that it's legally the PT's duty?

 

[truthseeker]

Fozzy,

I am glad that you posted here but somewhat concerned that all of your information seems to be coming from one source.

I have 20 years experience as a PT ATC. Personally, I prefer "evaluate and treat" but love it when a good NMSK evaluator puts their two cents on the form also. I like to hear what you "DON'T" want me to do.

Otherwise, I generally like to progress my patients based upon functional accomplishments rather than a calender.

I you have specific things that you would like us to try, by all means, write it down, but I think that it is important for you to understand that we are responsible for our treatment and we may prefer not to do something that is suggested for a whole host of reasons (not supported by evidence, it fosters dependence, patient can't come that often, etc . . .) As long as you also mark or write "eval and treat" the therapist and the patient understand that it is a fluid situation and that the PT has the discretion to modify the treatment plan as the patient's presentation changes.

 

[truthseeker]

fiveoboy,

read your posts back and tell me you don't sound a little defensive? I don't think you meant it that way.

 

[Fiveoboy11]

fiveoboy,

read your posts back and tell me you don't sound a little defensive? I don't think you meant it that way.

I didn't mean it that way, just trying to give my honest opinions, and say what I actually think

 

[fozzy40]

In all seriousness, is there even a need for a medical diagnosis? How does this change your treatment plan? As an example, can I put:
- "shoulder pain: evaluate and treat?"
or
- "RT hemiplegia: evaluate and treat?"

 

[Fiveoboy11]

Patient perception of what we say (providers) is something we all have troubles shaping. No matter how or what I tell a patient, they will interpret it however they will. Patients will believe whoever they ultimately trust. I've had patients who won't do certain things because their PCP or orthopedic surgeon said something to the contrary. Believe it or not, I've also had patients insist on getting inappropriate testing at the mention/suggestion of their physical therapist. I do agree that most physicians probably have no idea what is done in physical therapy. At the same time, identfying the need for a PT evaluation is a small victory for uninformed physicians in it of itself. We always have to give "a reason" and perhaps that is what the physician in your example came up with.


Most patients will need a reason when I order physical therapy. I don't think they would rest on "you need to see a physical therapist." I personally will give a functional goal to the patient as a reason.



Haha...frustrating but it happens all the time.


I understand that money drives most things in this world. However, this kind of pressure is what makes me leary of leaving duration of treatment completely unchecked. What do you mean that it's legally the PT's duty?

Giving a reason to the patient why you are referring to physical therapy is a great idea, there's nothing wrong with that. The problem is when a physician tells them what they are going to get, or what needs to be worked on specifically. Trust me, it doesn't help, completely skews everything. It makes no more sense than it would if you referred to a surgeon and told the patient that they "just need a little surgery."


A physical therapist shouldn't be suggesting specific medical diagnostic tests to the patient, similar to how a physician shouldn't suggest specific physical therapy intervention.

Leaving duration of treatment, and frequency unchecked would allow the most appropriate duration and frequency, based upon the physical therapist discretion. There is no way a physician who sees a patient 1x/month could more appropriately decide how long and often a patient should be seen, especially when they are not even the treating clinician. It just doesn't make sense.

Physical Therapists are legally the professionals who provide physical therapy, and manage the patient case from a physical therapy standpoint. At least in my state (AZ) and all other unrestricted direct access states. Some of these issues we are discussing are largely insurance related, baseless, and outdated.

 

[Fiveoboy11]

In all seriousness, is there even a need for a medical diagnosis? How does this change your treatment plan? As an example, can I put:
- "shoulder pain: evaluate and treat?"
or
- "RT hemiplegia: evaluate and treat?"

How about R shoulder pain, R hemiplegia, pos/neg subluxation x-ray/exam. More importantly: how chronic the issue/severity of the hemiplegia is would be a large factor. If it is relatively acute with a secondary issue shoulder pain and relatively severe, then I would think referral to outpatient neuro would be better. If it is chronic without as much severity/or generally not highly severe, outpatient ortho would be better. Just my opinions once again.

What you actually write on the script shouldn't impact the treatment plan very much. It is the actual patient issues and the evaluation that impact the treatment plan.

 

[fozzy40]

So a question about physical therapy school curriculum. With respect to low back pain, I've been reading about the different types of interventions i.e. specific exercise, manipulation, and stabilization techniques. Are all of these techniques taught in PT school? Do you have one particular philosophy/bias if you train at one physical therapy school versus another?

I try to use clinical prediction rules when evaluating my patients writing my notes. I'm not sure though if all therapists are trained in every technique.

 

[jesspt]

So a question about physical therapy school curriculum. With respect to low back pain, I've been reading about the different types of interventions i.e. specific exercise, manipulation, and stabilization techniques. Are all of these techniques taught in PT school? Do you have one particular philosophy/bias if you train at one physical therapy school versus another?

I try to use clinical prediction rules when evaluating my patients writing my notes. I'm not sure though if all therapists are trained in every technique.

Most student from most schools should have at least been introduced to the spinal manipulation clinical prediction rule. In order to be accredited, every school needs to include manipulation in its curriculum.

In regards to specific exercise and stabilization exercises, I think you would be hard pressed to find a PT school graduate that hasn't been instructed in these interventions. However, as with most interventions, it is the clinical decision making process, the determination of what to do when with whom, that can maximize an interventions effectiveness.

For example, students of the University of St. Augestine will be well versed in the examination and treatment of patients with musculoskeletal conditions from the Stanley Paris approach, as he is the President and founder of the university. It is a very pathoanatomical/biomechanical approach to patient assessment and their subsequent treatment. So, while they may know of the clinical prediction rule, they may be less likely to implement it than a graduate from Regis University (the current acdemic home of Dr. Tim Flynn who initially developed he CPR) because the CPR does not preferentially weigh the results of a biomechanical assessment.

 

[fozzy40]

I recently read this article:
Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC.
Evaluation of a treatment-based classification algorithm for low back pain: a
cross-sectional study. Phys Ther. 2011 Apr;91(4):496-509. Epub 2011 Feb 17.
PubMed PMID: 21330450.

While the point of the paper was to stratify patients into subgroups, would most physical therapists be comfortable with all these different treatment techniques since they may have some biases based on where they trained?

 

[jesspt]

I recently read this article:
Stanton TR, Fritz JM, Hancock MJ, Latimer J, Maher CG, Wand BM, Parent EC.
Evaluation of a treatment-based classification algorithm for low back pain: a
cross-sectional study. Phys Ther. 2011 Apr;91(4):496-509. Epub 2011 Feb 17.
PubMed PMID: 21330450.

While the point of the paper was to stratify patients into subgroups, would most physical therapists be comfortable with all these different treatment techniques since they may have some biases based on where they trained?

They would most likely be comfortable with most of the interventions, although a few may not perform manipulation regularly, due to graduating prior to manipulation being commonly taught in PT school curricula, or due to a lack of emphasis on that intervention in their ortho preparation.

Interesting article, with the results showing a greater level of cross-over between groups than one would like to see. There is a lot of face validity to sub-grouping of patients with low back pain, which makes me think that we must be missing some variables that are important in making those classifications more discrete.

 

[fozzy40]

They would most likely be comfortable with most of the interventions, although a few may not perform manipulation regularly, due to graduating prior to manipulation being commonly taught in PT school curricula, or due to a lack of emphasis on that intervention in their ortho preparation.

Interesting article, with the results showing a greater level of cross-over between groups than one would like to see. There is a lot of face validity to sub-grouping of patients with low back pain, which makes me think that we must be missing some variables with are important in making those classifications more discrete.

In my experience with spine care, a majority of the therapists I have worked are MDT trained. I have not really seen any variation in treatment of the patients at my institution. Since there is variation in training and practice styles, how do you suggest that I do my research when trying to learn about different therapists in my area?

 

[jesspt]

In my experience with spine care, a majority of the therapists I have worked are MDT trained. I have not really seen any variation in treatment of the patients at my institution. Since there is variation in training and practice styles, how do you suggest that I do my research when trying to learn about different therapists in my area?

Well, you can use the web sites from various organizations to find local therapists. Here are some examples:

McKenzie Institute:
http://www.mckenziemdt.org/therapis...&state=IL&ck=88826BDFD2C044E2C24B0E546DC815F4

American Academy of Orthopaedic Manual physical Therapists (AAOMPT):
Therapists listed here have either graduated from a manual physical therapy fellowship or have passed a competency examination (typically for foreign trained physios). Fellows will typically list their fellowship designation in their credentials - FAAOMPT.
http://aaompt.org/directory/fellowSearch.cfm

Board Certified Clinical Specialists:
Therapists listed here have undergone an extensive portfolio review as well as passed an examination in their area of specialty that is designed to represent knowledge necessary for advanced clinical practice. Some of these therapists may have also gone through a residency program accredited by the American Physical Therapy Association.
http://www.abpts.org/FindaSpecialist/

North American Institute of Orthopaedic Manual Therapy:
A continuing education provider who offers a manual therapy certification program, as well as an APTA accredited Orthopaedic Manual Physical Therapy fellowship program.
http://naiomt.com/www.naiomt.com/pages2/findcertpts.html

There are other Con Ed. providers who also offer manual therapy certification as well, such as Evidence In Motion, International Academy of Orthopaedic Manual Therapy, Maitland-Australian Physical Therapists, University of St. Augestine.

A word of caution - there is no accrediting body over manaul therapy certification programs, and therefore no oversight on what is included (or perhaps worse yet, what is not excluded) in the curriculum. All programs tend to be at least a little dogmatic and come from a more singular approach, such as Maitland (Australian), Paris, Cyriax, osteopathic, etc.

The American Board of Physical Therapy Specialties oversees the board certification of PTs and the American Physical Therapy Association in conjunction with the American Acedemy of Orthopaedic Manual Physical Therapists oversees and accredits ortho Manual therapy fellowship programs. Additionally, the APTA accredits residency programs in all of the areas where board certification is available: orthopaedics, sports, neurology, pediatrics, geriatrics, cardiopulmonary, women's health, and clinical electrophysiology. If a therapist is board ceritified, you will be able to tell from their credentials, as they will have a clinical specialist designation, such as OCS for orthopedic clinical specialist, NCS for neurology clinical specialist, etc.

Fozzy40 -

My two cents - find a board certified specialist or a fellowship trained therapist nearby, if possible. We don't have a lot of comparative data regarding the differnces in outcomes achieved by board certified specialists of graduates of manual therapy fellowship programs, but there is some preliminary research. In regards to board certified therapists outcomes vs. non-board certified therapists, there was no difference in outcome, but the board certified therapist achieved that outcome more quickly, in fewer visits. In regards to fellowship trained therapsts, the data is conflicting, with some studies showing superiority of fellowship trained therapists toucomes, and other studies showing no significant difference in outcomes.

That aside, if you find a board certified specialist in your area (and if you are in Chicago, it shouldn't be hard) they should be familiar with MDT (although they are likely not certified) as well as the application of manual therapy and can likely offer your patients a high quality episode of care.

 

[jesspt]

Oh, and for full disclosure, I am board certified in Orthopaedic Physical Therapy and am a Certified Manual Physical Therapist through the North American Institute of Orthopaedic Manual Therapy.

For Fozzy, and other potential referring providers who may be curious as to what all the letters behind various PTs' names are, my credentials look like this - Jesspt, PT, MS, OCS, CMPT, where PT is my professional designation, MS is the highest degree I have obtained, OCS indicates my area of board certification, and CMPT indicates that I am a certified manual physical therapist.

Yes, PT has an alphabet soup problem...

 

[fozzy40]

Awesome awesome stuff! Thank you so much

Well, you can use the web sites from various organizations to find local therapists. Here are some examples:

McKenzie Institute:
http://www.mckenziemdt.org/therapis...&state=IL&ck=88826BDFD2C044E2C24B0E546DC815F4

American Academy of Orthopaedic Manual physical Therapists (AAOMPT):
Therapists listed here have either graduated from a manual physical therapy fellowship or have passed a competency examination (typically for foreign trained physios). Fellows will typically list their fellowship designation in their credentials - FAAOMPT.
http://aaompt.org/directory/fellowSearch.cfm

Board Certified Clinical Specialists:
Therapists listed here have undergone an extensive portfolio review as well as passed an examination in their area of specialty that is designed to represent knowledge necessary for advanced clinical practice. Some of these therapists may have also gone through a residency program accredited by the American Physical Therapy Association.
http://www.abpts.org/FindaSpecialist/

North American Institute of Orthopaedic Manual Therapy:
A continuing education provider who offers a manual therapy certification program, as well as an APTA accredited Orthopaedic Manual Physical Therapy fellowship program.
http://naiomt.com/www.naiomt.com/pages2/findcertpts.html

There are other Con Ed. providers who also offer manual therapy certification as well, such as Evidence In Motion, International Academy of Orthopaedic Manual Therapy, Maitland-Australian Physical Therapists, University of St. Augestine.

A word of caution - there is no accrediting body over manaul therapy certification programs, and therefore no oversight on what is included (or perhaps worse yet, what is not excluded) in the curriculum. All programs tend to be at least a little dogmatic and come from a more singular approach, such as Maitland (Australian), Paris, Cyriax, osteopathic, etc.

The American Board of Physical Therapy Specialties oversees the board certification of PTs and the American Physical Therapy Association in conjunction with the American Acedemy of Orthopaedic Manual Physical Therapists oversees and accredits ortho Manual therapy fellowship programs. Additionally, the APTA accredits residency programs in all of the areas where board certification is available: orthopaedics, sports, neurology, pediatrics, geriatrics, cardiopulmonary, women's health, and clinical electrophysiology. If a therapist is board ceritified, you will be able to tell from their credentials, as they will have a clinical specialist designation, such as OCS for orthopedic clinical specialist, NCS for neurology clinical specialist, etc.

Fozzy40 -

My two cents - find a board certified specialist or a fellowship trained therapist nearby, if possible. We don't have a lot of comparative data regarding the differnces in outcomes achieved by board certified specialists of graduates of manual therapy fellowship programs, but there is some preliminary research. In regards to board certified therapists outcomes vs. non-board certified therapists, there was no difference in outcome, but the board certified therapist achieved that outcome more quickly, in fewer visits. In regards to fellowship trained therapsts, the data is conflicting, with some studies showing superiority of fellowship trained therapists toucomes, and other studies showing no significant difference in outcomes.

That aside, if you find a board certified specialist in your area (and if you are in Chicago, it shouldn't be hard) they should be familiar with MDT (although they are likely not certified) as well as the application of manual therapy and can likely offer your patients a high quality episode of care.

 

[mtm34]

Jess (or anyone who wants to chime in)
I'll be graduating next year and would like to specialize in orthopedics, it seems pursuing an OCS is the logical first step- first off do you recommend doing a residency after graduating to obtain the certification faster? Secondly, what manual therapy tract do you recommend?

 

[jesspt]

Jess (or anyone who wants to chime in)
I'll be graduating next year and would like to specialize in orthopedics, it seems pursuing an OCS is the logical first step- first off do you recommend doing a residency after graduating to obtain the certification faster? Secondly, what manual therapy tract do you recommend?

I think that I would probably recommend a residency, as a few PTs are doing them right out of school now, and, as you say, it does allow you to sit for the OCS exam in a more timely fashion than you might otherwise.

I guess I would recommend you consider the Evidence in Motion or Regis residency programs, as their faculty include some prominent clinician researchers such as Julie Fritz, Julie Whitman, Tim Flynn and John Childs, etc. It is also set up in a distance learning format, so you can be employed full time and still go through the program. And, if you are able to find a job where a therapist is already board certified, you can get your 1:1 mentorship hours finished fairly painlessly.

 

[Danae00]

Forewarning: I'm a student with limited clinical experience!

- diagnosis with an idea of where is the problem (i.e. RTC impingement 2/2 scapular dyskinesis)

Quite helpful. But we will still do a full assessment to see if we come up with the same diagnosis as it relates to the patient's limited mobility. Many MDs are not good at diagnosing MSK problems so we are taught to take their diagnosis with a grain of salt. That said, I haven't had any referrals from physiatrists' before and I imagine I'd just their opinion more.

- weight bearing precautions
- ROM limitations

Great! But if the precautions / limitations seem really out of left field I might give you a call to clarify why they are in place.

I'm assuming you are talking about ROM limitations as in contraindications as opposed to what the patient's current ROM is. If's it's the later we will find that out very quickly in our assessment it's not really necessary.

- directional preference when appropriate
- frequency and duration

I'd say leave these out. This is getting more into treatment parameters and I don't feel it's really appropriate on a referral.


Now things that I would like to see are:

* Functional goals that your patient has verbalized to you ("pt wishes to be able to walk daughter down the aisle at wedding in 6 weeks")

* Problems that you foresee which might limit rehab ("pt only has 3 sessions covered by insurance and is unsure if they can afford more").


But really? Assess and treat should work just fine for most non-complex patients.

We are trained to figure out the rest ourselves. Additional information IMO falls somewhere on the continuum between "awesome! that's great to know!" and "@#$#! This MD is trying to tell me how to do my job". And the same piece of advice might fall on opposite ends of the scale depending on the PT receiving it! Heh.

 

[fozzy40]

In my residency, we are actually taught to be as descriptive as possible when writing physical therapy prescriptions. In my mind, "low back pain: evaluate and treat" is similar to me writing "infection: take antibiotics" on a prescription pad. Since many of the posters believe that physicians have poor MSK exam skills I guess I would think that it's nice to receive a descriptive prescription (assuming it's correct) as it might be an indicator that there is some "thinking" behind what is being written. Encouraging physicians to just write "evaluate and treat" almost seems like a step in the wrong direction from and educational standpoint.

For some of you the perception is that a "physician is trying to tell you your job", can you give me examples of this?

 

[Fiveoboy11]

An antibiotic and physical therapy are not the same things. Physical Therapy is not a medical procedure. It is a professional discipline separate and distinct from medicine with specialists (PT's), who provide it. When you write a script for physical therapy you are referring to a specialist.

 

[fozzy40]

An antibiotic and physical therapy are not the same things. Physical Therapy is not a medical procedure. It is a professional discipline separate and distinct from medicine with specialists (PT's), who provide it. When you write a script for physical therapy you are referring to a specialist.

Agreed, but that was not the point of my analogy. My point is about giving a specific direction versus just being vague.

 

[Fiveoboy11]

Agreed, but that was not the point of my analogy. My point is about giving a specific direction versus just being vague.

It is very common for physician's to give specific direction for PT intervention. I've had physician's call to tell me to work on ROM exclusively for s/p TKA pt's. I've had physician's tell me to do "Williams flexion exercises and hot pack" for LBP. Hot pack, massage, ROM for s/p MVA. I could write down in detail numerous times I've encountered this. Sometimes the script is vague, but at the same time giving direction on what should be performed, many times inappropriate.

It all comes back to physician's thinking they are in charge of physical therapy. And that was the point of my previous post.

 

[Fiveoboy11]

Personally, I would love to see the physician's notes on a patient because I think this would be more informative and would provide the physician assessment too. So, could physician's fax these documents to the PT, or do you think we should ask for them? Perhaps that would help with outcomes.

 

[jesspt]

In my residency, we are actually taught to be as descriptive as possible when writing physical therapy prescriptions. In my mind, "low back pain: evaluate and treat" is similar to me writing "infection: take antibiotics" on a prescription pad. Since many of the posters believe that physicians have poor MSK exam skills I guess I would think that it's nice to receive a descriptive prescription (assuming it's correct) as it might be an indicator that there is some "thinking" behind what is being written. Encouraging physicians to just write "evaluate and treat" almost seems like a step in the wrong direction from and educational standpoint.

For some of you the perception is that a "physician is trying to tell you your job", can you give me examples of this?

Fozzy,

I don't think many PT's would object to a prescription written as you have described it. I think where some of the frustration you can sense in some of the posts comes from is that these types of prescriptions are so rare. I can probably count on two hands the times a prescription for a non-surgical patient has actually been helpful during my 13 years as a PT. It is far more likley that I get the "neck pain s/p MVA. PT for ROM, US, e-stim, moist heat." So, having the patient's best interest in mind, I screen for red flags, occasionally performing a cranial nerve screen, looking at Hoffman's reflex and long tract signs if I suspect some upper motor neuron issue and if all that is negative, proceed to ignore most of the interventions that were on the prescription because they encourage passive coping mechanisms, which our best research shows us are predictive of a worse outcome and can quite possibly make it more likely the patient will transition to chronic pain.

An example from yesterday -

50 year old woman walks into my clinic having seen an orthopod on 5/17. The prescription reads "Dx; (R) adhesive capsulitis. US, ROM, scapular stabilization. So, taking the exam findings out of it and just looking at the interventions this MD would like me to perform, I can already see some problems. First off, US. See the study below:

http://ptjournal.apta.org/content/89/5/419.full

Now, in summary, patients with frozen shoulder who received US were 19-32% less likely to improve. Additionally, other modalities and passive treatment interventions were also implicated as treatment interventions that make it less likely for a patient to improve.

Scapular stabilization? Really? Now, perhaps I've missed something, but I don't think I have ever seen any literature on the correlation between scapular instability/dyskinesia and adhesive capulsitis. Nor have I seen that addressing AC with scapular stabilziation exercises results in improvements in their GH joint ROM, which is the primary impairment of a patient with adhesive capsulitis, assuming they have been correctly diagnosed. Of course, abscence of evidence isn't necessarily lack of efficacy, but if the patient truly has adhesive capsulitis I'll probably be better served spendign the majority of my treatment time addressing her primary impairment - loss of ROM - rather than being concerned that she can't quite seem to keep her scapula retracted and depressed when attempting to elevate her arm.

So, I have a prescription which tells me two things I can use. 1) the MD suspects the patient has adhesive capsulitis, and 2) he thinks I should treat them with ROM. Now, do you really think that any PT with a license can't come up with that treatment intervention?

So, in short, I would welcome a prescription that is descriptive of the patient's condition, with pertinent examination findings and suggestions regarding interventions that are well supported by literature or at least are based on sound scientific theory. But, they are are about as common as the jackalope (http://en.wikipedia.org/wiki/Jackalope).

I applaud you for making yourself aware of the relevant PT literature, particularly regarding LBP. You seems to respect your profession as well as physical therapy's place in the conservative care of musculoskeletal injuries. Thank you for contributing to the PT forum.

 

[fozzy40]

jesspt,

I understand your point. However, I think that most physicians don't put a lot of thought into their prescriptions for physical therapy so they end up putting in things for you to consider. I have seen scripts like that I guess I see them more as suggestions versus this is what I think you should do. I think if you called up the physician and said that you don't think that US would be beneficial they would probably say that that's fine and do what you think is best. I'm sure many of you are thinking then, "why write it all?" I suspect it's for documentation sake.

Have you guys ever had a physician say, "no, this is specifically what I want?"

 

[fozzy40]

Personally, I would love to see the physician's notes on a patient because I think this would be more informative and would provide the physician assessment too. So, could physician's fax these documents to the PT, or do you think we should ask for them? Perhaps that would help with outcomes.

I think that this is a great idea. At my institution, PTs and Physicians have a common EMR and we are able to see each others notes. I know that I look at their notes. What type of stuff would you be interested in reading? Physical findings on our examination?

 

[Fiveoboy11]

I think that this is a great idea. At my institution, PTs and Physicians have a common EMR and we are able to see each others notes. I know that I look at their notes. What type of stuff would you be interested in reading? Physical findings on our examination?

I personally like to skim through and read anything in detail I feel is important such as the history, I've seen many progressions through physician (especially surgeon) protocol as far as medically so it is nice to get a feel for what they have gone through prior to referral. Besides this it is very nice to have all pertinent imaging results right there to read, op reports, any procedure reports and the physician assessment or what they feel is going on. I have been in one clinic where the EMR was shared as well and it was awesome, it felt like there was more mutual respect and the physician could actually see what a PT can do and what we know if they wanted. Wouldn't it be nice if there was a universal EMR that everyone by law had to use? It would be infinitely beneficial to the patient/clinicians if you ask me, cost effective and efficient.

You posted prior to jesspt,

I think what a physician writes on a script is what they want performed, maybe in some cases it is suggestions, but if the sh$t hits the fan for one reason or another, don't think the physician won't throw the PT right under the bus and say "well I didn't write that on the script." Or, "that's not what I wanted." I've worked in many outpatient clinics where owners pressure you to do exactly as it says on the script. Physician's overall don't have a clue what we do, and it doesn't take long to figure that out (you don't even have to be a PT to see it). Just look at the video posting on Giffords where Dr. Gupta talks about how he has very little to no experience with rehab or the therapy specialties. The scary fact is he has been writing scripts for years. Perhaps medical school/residencies should be more collaborative with the rehab specialties and stop thinking of it as something that needs to be precisely documented on a script when they refer.

 

[fozzy40]

I think what a physician writes on a script is what they want performed, maybe in some cases it is suggestions, but if the sh$t hits the fan for one reason or another, don't think the physician won't throw the PT right under the bus and say "well I didn't write that on the script." Or, "that's not what I wanted." I've worked in many outpatient clinics where owners pressure you to do exactly as it says on the script.

On the flip side, a script that solely says "evaluate and treat" could also be looked at as not specific enough and could put both parties at risk still should there be a bad outcome i.e. Physician says "I didn't say you could do that" and PT says "but you didn't specify that I could not do that."

Physician's overall don't have a clue what we do, and it doesn't take long to figure that out (you don't even have to be a PT to see it). Just look at the video posting on Giffords where Dr. Gupta talks about how he has very little to no experience with rehab or the therapy specialties. The scary fact is he has been writing scripts for years. Perhaps medical school/residencies should be more collaborative with the rehab specialties and stop thinking of it as something that needs to be precisely documented on a script when they refer.

Believe me brotha...you are preaching to the choir! As you said, most medical specialties do not understand the rehabilitation model and it's not like physiatry is any better understood compared to PT, OT, SLP, etc. Believe me on that. I have a friend that's a PT who went back to med school and said he had no idea what physiatrists do when he was still practicing!

I do agree that there is a huge educational deficit between allied health and medical school curriculum. We (physiatrists) have been working on trying to get some of the medical rehab issues that we see to be taught at the medical school level.

Has the APTA ever tried working with the LCME or the AOA in trying to incorporate some education into the undergraduate medical curriculum?

 

[Fiveoboy11]

A physician is not legally responsible for what a PT does, a PT is a separate professional that deals with the consequences of their own actions. PT's develop the treatment plan and administer it, so they are responsible for it. I agree there are PT's who would say something like what you mentioned before, but would not occur nearly as often as a physician throwing a PT under the bus in my opinion. Why? Because more physician's think they are in charge of physical therapy versus physical therapists thinking physician's are in charge of physical therapy. It could happen in two ways (a PT doing something that isn't on the script, and not doing something that is). I could see a PT saying something like that if a surgeon referred without any precautions if there were supposed to be, but hardly ever otherwise.

I'm not quite sure how much collaboration the APTA has with other professional organizations. I know the APTA recently met with the AMA regarding educational material of the PT profession which apparently went well.

How has physician professional training changed to reflect improvement in training of other professional disciplines? Does the medical community have any grasp on how well educated PT's are relative to what they do?

 

[fozzy40]

A physician is not legally responsible for what a PT does, a PT is a separate professional that deals with the consequences of their own actions. PT's develop the treatment plan and administer it, so they are responsible for it. I agree there are PT's who would say something like what you mentioned before, but would not occur nearly as often as a physician throwing a PT under the bus in my opinion. Why? Because more physician's think they are in charge of physical therapy versus physical therapists thinking physician's are in charge of physical therapy. It could happen in two ways (a PT doing something that isn't on the script, and not doing something that is). I could see a PT saying something like that if a surgeon referred without any precautions if there were supposed to be, but hardly ever otherwise.

That's a pretty big generalization that physicians are likely to throw anybody under the bus.

How has physician professional training changed to reflect improvement in training of other professional disciplines? Does the medical community have any grasp on how well educated PT's are relative to what they do?

I suspect that this is done differently at different medical schools. I know at my school we have a couple of lectures on different health care professions but like I said there's probably some variability. However, I would not necessarily count on the "community" to seek out education about other fields. Even as a physiatrist, it's really up to us to go out and educate even our colleagues let alone the larger community.

 

[jesspt]

jesspt,

I understand your point. However, I think that most physicians don't put a lot of thought into their prescriptions for physical therapy so they end up putting in things for you to consider. I have seen scripts like that I guess I see them more as suggestions versus this is what I think you should do. I think if you called up the physician and said that you don't think that US would be beneficial they would probably say that that's fine and do what you think is best. I'm sure many of you are thinking then, "why write it all?" I suspect it's for documentation sake.

Have you guys ever had a physician say, "no, this is specifically what I want?"

Fozzy,

I agree that if I called up this physician he would essentially give me the verbal green light to do whatever I wanted. But, I disagree with your supposition that it is for documentation purposes. In the private practice realm I can't imagine why he or she would need to make suggestions for documentation purposes. Perhaps I am missing something?

And, of course, I have had physicians say that they only wish what they have prescribed to be performed. One particular recent example comes to mind. In our clinic a few months ago, a patient was referred from a neurologist for cervical traction, diagnosis cervicalgia. Physical exam revealed bilateral medial thigh numbness and "an electric shock down the legs" every time she would flex her cervical spine maximally. My colleague contacted the doctor who was resistant to performing any imaging and insisted we perform the cervical traction. So, we sent her to another physican who ordered an MRI of the upper cervical region and the brain. Highly suggestive of demyelinating disease.

Now, this is an extreme example, and the situations where a physician is so incredibly insistent are very rare, but they do occur. And, I would imagine that if you spoke to quite a few PTs, that well over half of them would say they have encountered a doctor who was very rigid about what could be performed on the patients they refer.

In regards to the APTA working with the LCME, I'm not sure it is even on their radar. Currently they are battling it out on capital hill with the AMA and the AAOS regarding physican-owned physical therapy practices and direct access to PT services. I don't think they're focused on much more than that right now.

 

[fozzy40]

Fozzy,

I agree that if I called up this physician he would essentially give me the verbal green light to do whatever I wanted. But, I disagree with your supposition that it is for documentation purposes. In the private practice realm I can't imagine why he or she would need to make suggestions for documentation purposes. Perhaps I am missing something?

Well, when I document there has to be a reason behind it. As an example, I don't document that I referred a patient to neurosurgery for "neck pain." It's usually followed by some more specifics like for evaluation of syrinx or cervical myelopathy. I use the same approach when writing therapy prescriptions. I'm not insisting on a treatment plan or protocol just trying to give a heads up on what I'm thinking.

And, of course, I have had physicians say that they only wish what they have prescribed to be performed. One particular recent example comes to mind. In our clinic a few months ago, a patient was referred from a neurologist for cervical traction, diagnosis cervicalgia. Physical exam revealed bilateral medial thigh numbness and "an electric shock down the legs" every time she would flex her cervical spine maximally. My colleague contacted the doctor who was resistant to performing any imaging and insisted we perform the cervical traction. So, we sent her to another physican who ordered an MRI of the upper cervical region and the brain. Highly suggestive of demyelinating disease.

That bends both ways as well. I've met PTs that are just as resistant and closed minded.

In regards to the APTA working with the LCME, I'm not sure it is even on their radar. Currently they are battling it out on capital hill with the AMA and the AAOS regarding physican-owned physical therapy practices and direct access to PT services. I don't think they're focused on much more than that right now.

Something to consider in the future perhaps.

 

[jesspt]

Well, when I document there has to be a reason behind it. As an example, I don't document that I referred a patient to neurosurgery for "neck pain." It's usually followed by some more specifics like for evaluation of syrinx or cervical myelopathy. I use the same approach when writing therapy prescriptions. I'm not insisting on a treatment plan or protocol just trying to give a heads up on what I'm thinking.



That bends both ways as well. I've met PTs that are just as resistant and closed minded.


Something to consider in the future perhaps.

Fozzy,

From out interactions here, I have no doubt that your examination, interventions and therapy prescriptions are indeed well thought out. And you certainly seem to be the collaborative sort. I'm sure that the therapists you work with are appreciative of that, beleive me.

In regards to stubborness, closed-mindedness, etc. - You're absolutely right. You have asked for examples, so I provided you some from my experiences. I am not attempting to portray PTs as the ideal health care professional, devoid of all fault. I think that PTs are like MDs, OTs, DOs, Dentists, etc. in that most are average, some are exceptional, and some are horrible. I also think that no matter which of the previous groups they fall into, almost all are well-intentioned.

 

[fozzy40]

Jesspt,

Since you mentioned the scapula I just ran across this great review article on the scapula if you haven't seen this already.
http://academics.uky.edu/cohs/rhbphd/Documents%20for%20RHB%20NEWS%20Blog/November2009ScapularSummit.pdf

 

[jesspt]

Jesspt,

Since you mentioned the scapula I just ran across this great review article on the scapula if you haven't seen this already.
http://academics.uky.edu/cohs/rhbphd/Documents for RHB NEWS Blog/November2009ScapularSummit.pdf

Thanks for the reference!

I haven't seen this previously. Some of the best and brightest minds regarding the shoulder put this together. McClure is on faculty at my alma mater and Uhl and Kiebler always make for good reading.

 

[fozzy40]

I've been lucky to attend two shoulder symposiums and heard these guys talk. The sources cited are invaluable as well. It basically saves the reader hours of sifting through the literature.

 

[Sherriebootht]

wheres the fast acting bronchodilator? There is no albuterol to be used as a rescue medication.