How much latitude do you give physio?

[ghost dog]

When working in conjunction with a physiotherapist, and referring a pt: I'll typically write on a requistion (for example) " pt has discogenic back pain x 3 months , please assess and treat "

Are you folks more specific; i.e : Mckenzie exercises , etc ?

Does anyone go over specific exercises themselves with patients for chronic back pain (for example) ?

Apologies if these are stupid questions.

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[lobelsteve]

When working in conjunction with a physiotherapist, and referring a pt: I'll typically write on a requistion (for example) " pt has discogenic back pain x 3 months , please assess and treat "

Are you folks more specific; i.e : Mckenzie exercises , etc ?

Does anyone go over specific exercises themselves with patients for chronic back pain (for example) ?

Apologies if these are stupid questions.

It is dependent on your relationship and knowledge of that PT skill set.
I get crazy specific if it's a therapist I don't know and a complicated patient. It's eval and treat if it's my PT and something easy like SIJ.

I do provide Counselling in the office for various exercises specific to the Dx.

 

[RUOkie]

When working in conjunction with a physiotherapist, and referring a pt: I'll typically write on a requistion (for example) " pt has discogenic back pain x 3 months , please assess and treat "

Are you folks more specific; i.e : Mckenzie exercises , etc ?

Does anyone go over specific exercises themselves with patients for chronic back pain (for example) ?

Apologies if these are stupid questions.

I agree with Steve.

I have one PT in my town who still does shake & bake for all back pain patients, and her clinic has an exclusive insurance contract (luckily only one). If I have to send a patient there, I write a full page of orders, and have them send me weekly notes. Another clinic I work with I write the diagnosis (ie SIJ/discogenic/radic) and eval and treat.

 

[fozzy40]

I try to be as specific as possible without trying to tell them how to do their job. However, I think that the "dirty secret" is that they do what they want to do anyways.

 

[jesspt]

I try to be as specific as possible without trying to tell them how to do their job. However, I think that the "dirty secret" is that they do what they want to do anyways.

All right Fozzy. I'll fess up. I generally view what is written on the prescription pad as a suggestion, and then modify it if needed based on findings at the initial evluation. If it's a doctor that I don't know at all, I'll try to give them a call and discuss it with them.

Those of you who write someting more specific, say Mckenzie exercises. Do you do this based on the presence of directional preference or centralization on physical exam, or primarily based on imaging? The reason I ask is I bet that well over 50% of the patients that get sent to me with Mckenzie exercises on the prescription don't have either directional preference or centralization, and I'm wondering if the MD/DO just wrote that becuase they automatically associate McKenzie with discogenic pain.

 

[fozzy40]

jesspt! Long time no hear

Jesspt have had this discussion on another thread. I actually write my prescriptions as suggestions as jesspt has alluded to. I do have certain cases where I will explicitly say absolutely not to use certain modalities or techniques.

 

[Phillyborn]

jesspt! Long time no hear

Jesspt have had this discussion on another thread. I actually write my prescriptions as suggestions as jesspt has alluded to. I do have certain cases where I will explicitly say absolutely not to use certain modalities or techniques.

http://forums.studentdoctor.net/showthread.php?t=821663

Here is the link to the above mentioned post. I remember reading the thread as it unfolded and found it pretty enlightening.

 

[ghost dog]

All right Fozzy. I'll fess up. I generally view what is written on the prescription pad as a suggestion, and then modify it if needed based on findings at the initial evluation. If it's a doctor that I don't know at all, I'll try to give them a call and discuss it with them.

Those of you who write someting more specific, say Mckenzie exercises. Do you do this based on the presence of directional preference or centralization on physical exam, or primarily based on imaging? The reason I ask is I bet that well over 50% of the patients that get sent to me with Mckenzie exercises on the prescription don't have either directional preference or centralization, and I'm wondering if the MD/DO just wrote that becuase they automatically associate McKenzie with discogenic pain.

Would you comply with an MD request for weekly f/u physio TX notes ?

Very helpful and interesting feedback, everyone.

Cheers.

 

[jesspt]

Would you comply with an MD request for weekly f/u physio TX notes ?

Very helpful and interesting feedback, everyone.

Cheers.

Sure. It's standard practice at my clinic to dictate a progress note every two weeks, so it would be easy to do it weekly.

You may want to specify to the PT what info you want, such as Oswestry score, Roland-Morris, treatments that have been utilized, etc.

 

[fozzy40]

How about FABQ? Do you routinely score this? Can you if I ask for it?

 

[jesspt]

How about FABQ? Do you routinely score this? Can you if I ask for it?

I don't always give it to everybody, but most of my patients get it, or the Tampa Kinesiophobia scale, or both. Andi f they get it, the score is included in the initial assessment that is dictated and sent to the referring provider.

 

[Jitter Bug]

Depends on my relationship with the PT. I don't send patients to PT's unless I know we are on the same wavelength regarding treatment. If its clear the PT is working 100% independently of my prescription then I wish them well and take my business elsewhere. I have my trusted regular PT's who I give a lot of freedom to treat (ie keep the script pretty generic) because they have a demonstrated pattern of good results and happy patients.

If the patient requests someone specific that I don't know, I will either call to discuss or write very specific orders. There's alot of abuse in my city with PT's running 3 rooms at once with traction, TENS, while the 3rd gets a nice U/S massage.

I want my patient to get their money's worth. Unless it's acute, I generally dont have any interest in my patients receiving passive modalities.

 

[Fiveoboy11]

Depends on my relationship with the PT. I don't send patients to PT's unless I know we are on the same wavelength regarding treatment. If its clear the PT is working 100% independently of my prescription then I wish them well and take my business elsewhere. I have my trusted regular PT's who I give a lot of freedom to treat (ie keep the script pretty generic) because they have a demonstrated pattern of good results and happy patients.

If the patient requests someone specific that I don't know, I will either call to discuss or write very specific orders. There's alot of abuse in my city with PT's running 3 rooms at once with traction, TENS, while the 3rd gets a nice U/S massage.

I want my patient to get their money's worth. Unless it's acute, I generally dont have any interest in my patients receiving passive modalities.

Keep in mind many referring providers write "US/massage" on the script, including physicians. And I would not be surprised if the clinics you say are abusive have PTA's running the show (after the PT does the IE, and then gets passed off to the PTA) or "old school" BSPT's providing the care.

If the PT is thorough and practices in an evidence based and impairment based manner there is no reason the PT should not be afforded autonomy. The PT treatment is based upon the PT eval, not on a script from a physician. Physical Therapy is a specialty, it is not a medical procedure that can be ordered and just carried out as a script says.

 

[fozzy40]

And I would not be surprised if the clinics you say are abusive have PTA's running the show (after the PT does the IE, and then gets passed off to the PTA) or "old school" BSPT's providing the care.

This may be true but I assume that the PTA is under the direction of the PT. This was my experience as a former PTA.

If the PT is thorough and practices in an evidence based and impairment based manner there is no reason the PT should not be afforded autonomy. The PT treatment is based upon the PT eval, not on a script from a physician. Physical Therapy is a specialty, it is not a medical procedure that can be ordered and just carried out as a script says.

What's difficult is that there is so much variability in how PTs are trained and ultimately how they practice. This is why I make it a point to stay up to date on the PT literature and talk with PTs I do not know.

 

[Fiveoboy11]

This may be true but I assume that the PTA is under the direction of the PT. This was my experience as a former PTA.


What's difficult is that there is so much variability in how PTs are trained and ultimately how they practice. This is why I make it a point to stay up to date on the PT literature and talk with PTs I do not know.

PTA supervision is definitely business and clinic dependent. Within the company I work for PRN, there is huge variability in the techs, front office, and PTA's in terms of knowledge of their roles. I've been around many techs who masquerade as a PT in only 3 years of experience. The clinic I've been working at M-W the past 3 weeks, the PTA had been doing lotiony massages, hot pack/e-stim on literally every patient. I've had to train her to actually read the eval, and do treatment based on the POC. The tech was doing manual treatments on my first day too. So, if there appears to be inappropriate treatments and/or overutilization of modalities, do not be surprised if it is a scenario as above.

Sadly, many co-workers within the PT realm do not think they are answerable to the PT.

 

[fozzy40]

Wow.

Do the PTAs bill? Who is accountable for management of the patient's time and charges?

 

[Fiveoboy11]

Wow.

Do the PTAs bill? Who is accountable for management of the patient's time and charges?

Yeah, I know.

Yes they bill, as far as being accountable for their actions, I would at least hope that in this particular circumstance, the PTA is alone on that one. I've done everything I can up to now to get adherence to the POC, so if it's not followed I can't do much about it. I have spoken to the regional manager of the company numerous times about issues and she is helping me. Supposedly, I'm there to "fix" the clinic. In terms of insurances, I am truly afraid of any punishment they have power to impose, because it is justified to audit this place and demand back lots of money. And the PTA writes my name and PT with my license number on every note she does, then circles that I was consulted during the Rx, when I never was, and often when I was not even in the clinic that day. Lots of work for me to do at this place...

 

[fozzy40]

And the PTA writes my name and PT with my license number on every note she does, then circles that I was consulted during the Rx, when I never was, and often when I was not even in the clinic that day. Lots of work for me to do at this place...

Well, that just sounds like unethical on the part of the PTA and for the management for condoning. I hope you put a stop to that.

Are many clinics like this? How is it that the PTs (in this clinic) don't have more control over what they are doing? Isn't the job of the PT-aide to "aide" or "assist" in the outlined care plane designed by the treating therapist?

 

[jesspt]

I don't send patients to PT's unless I know we are on the same wavelength regarding treatment.

I get the vibe that this is the prevailing opinion by the physicians who are posting on this thread. My concern is just what is that "wavelength." There are A LOT of physicans in my area who are caring for patients with musculoskeletal complaints who may have a good idea of how to manage those patients medically, but have little idea of how to provide rehabilitation for them. I am certainly not implicating those who are participating in this forum, but I think with some reflection on your peers, many of you will agree with me.

I still get an incredibly high number of prescriptions requesting (and I use this term liberally, as I am sure that those who are putting in down on paper are expecting it to be done) US, e-stim, heat. Several times a year I will get prescriptions for myofascial release or some other more "fringe" intervention. Many times the prescription for these passive treatments is carried to me by a patient who has chronic symptoms and are exhibiting huge amounts of fear-avoidance behaviors and have fallen into a reliance on passive coping strategies as they attempt to manage their symptoms. So, here I am, on the raggedy edge. Should I blindy follow the prescription handed to me by the patient (full of treatments that are nearly certain to leave this patient's symptoms unchanged at best, or possibly leave them worse), or do I use the results of my exam, the current literature relevant to the patient's clinical signs and symptoms, and the patient's input to guide me? I invariably side with my responsibility to my patient, and my concsience, and provide them with the treatment that seems to be the best for their given situation, trying to use research and reason, when and where it exists. Have I taken to much "liberty" here? Do I expect to much "latitude"?

I applaud the posters on this forum for your attempt to communicate with the therapists to whom you refer patients. Establishing a real professional and collegial relationship with local PTs should enhance your practice and your patient outcomes. There are a great many PTs who stay abreast of the relevant literature, and, if they have omitted some treatment that you wrote on a prescription, did so because when the research, their clinical experience, and the patient's presentation (including their expectation, values and preferences) all collided the day the PT treated them, that treatment didn't seem to be in the bets interest of getting the patient better. Nothing more, nothing less, and certainly nothing malicious.

 

[jesspt]

Five,

And I would not be surprised if the clinics you say are abusive have PTA's running the show (after the PT does the IE, and then gets passed off to the PTA) or "old school" BSPT's providing the care.

A PT with a clinical doctorate degree, or a Master's degree or a Bachelor's degree can all practice in an ineffective fashion. In my experience, the PT's level of education rarely is predictive of this, rather it is their engagement with their profession.

 

[PMR2008]

I still get an incredibly high number of prescriptions requesting (and I use this term liberally, as I am sure that those who are putting in down on paper are expecting it to be done) US, e-stim, heat. Several times a year I will get prescriptions for myofascial release or some other more "fringe" intervention. Many times the prescription for these passive treatments is carried to me by a patient who has chronic symptoms and are exhibiting huge amounts of fear-avoidance behaviors and have fallen into a reliance on passive coping strategies as they attempt to manage their symptoms. So, here I am, on the raggedy edge. Should I blindy follow the prescription handed to me by the patient (full of treatments that are nearly certain to leave this patient's symptoms unchanged at best, or possibly leave them worse), or do I use the results of my exam, the current literature relevant to the patient's clinical signs and symptoms, and the patient's input to guide me?

Since the doctor is the one who wrote the script and you might not be aware of what literature the doctor might be using..or what the circumstances are...you have to either follow what the script says or you have the responsibility to contact the doctors office and inform him/her that the treatment is not appropriate etc. Once I am in private practice if a PT decides to ignore my instructions...regardless of who well my patients like the PT I will make it a point to contact the PT and communicate my disapproval. It is a matter of professional courtesy.

 

[jesspt]

Since the doctor is the one who wrote the script and you might not be aware of what literature the doctor might be using..or what the circumstances are...you have to either follow what the script says or you have the responsibility to contact the doctors office and inform him/her that the treatment is not appropriate etc. Once I am in private practice if a PT decides to ignore my instructions...regardless of who well my patients like the PT I will make it a point to contact the PT and communicate my disapproval. It is a matter of professional courtesy.

Does the doctor then have the responsibility to indicate to the PT what literature he/she is using, or what those extenuating circumstances are? Seems as though professional courtesy should be a two-way street.

As I posted previously:

I generally view what is written on the prescription pad as a suggestion, and then modify it if needed based on findings at the initial evluation. If it's a doctor that I don't know at all, I'll try to give them a call and discuss it with them.

 

[Fiveoboy11]

Since the doctor is the one who wrote the script and you might not be aware of what literature the doctor might be using..or what the circumstances are...you have to either follow what the script says or you have the responsibility to contact the doctors office and inform him/her that the treatment is not appropriate etc. Once I am in private practice if a PT decides to ignore my instructions...regardless of who well my patients like the PT I will make it a point to contact the PT and communicate my disapproval. It is a matter of professional courtesy.

It would be courteous for a physician to recognize they are not the physical therapist. The above post demonstrates little to no mutual collaboration which is the way PT/physician interaction has been in the past and still is a fair amount now. It obviously doesn't work and doesn't even approach being optimal for the patient.

 

[PMR2008]

It would be courteous for a physician to recognize they are not the physical therapist. The above post demonstrates little to no mutual collaboration which is the way PT/physician interaction has been in the past and still is a fair amount now. It obviously doesn't work and doesn't even approach being optimal for the patient.

I understand your statement. But PTs have to be aware of who is prescribing. There is a big difference in the MSK knowledge level of a internist vs a well trained Physiatrist/Orthopod/Sports med doc. I know plenty of doctors who were either PTs or PTAs prior to medical school. Mutual collaboration means open lines of communication. If a PT can explain to me why he/she thinks a certain modality or technique I requested is not appropriate I will understand. When it is completely ignored even with warnings I will find a different PT.

 

[Fiveoboy11]

I understand your statement. But PTs have to be aware of who is prescribing. There is a big difference in the MSK knowledge level of a internist vs a well trained Physiatrist/Orthopod/Sports med doc. I know plenty of doctors who were either PTs or PTAs prior to medical school. Mutual collaboration means open lines of communication. If a PT can explain to me why he/she thinks a certain modality or technique I requested is not appropriate I will understand. When it is completely ignored even with warnings I will find a different PT.

PT's prescribe physical therapy, and noone else. Physician's refer to physical therapy. There is a big difference in knowledge level of a PT in relation to PT vs any physician, regardless of training. If you think it is appropriate for you to request a certain technique then you should also feel it's ok for a PT to request you prescribe a certain medication, or test. It's the same thing.

 

[PMR2008]

There is a big difference in knowledge level of a PT in relation to PT vs any physician, regardless of training.

I am sorry but that is a very general statement. Not all docs or PTs are created equally.

If you think it is appropriate for you to request a certain technique then you should also feel it's ok for a PT to request you prescribe a certain medication, or test. It's the same thing.

There have been many times when because of a recommendation from a PT I trust I have ordered imaging and medications. So yes this is true mutual collaboration. Until PTs can have complete autonomy they are obliged to respect what is written on the prescription and have open lines of communication.

 

[fozzy40]

Open line of communication is key and mutual respect seems to be the underlying theme!

When I write a script, they are usually of things I think may help and are to be taken as suggestions and not directives

Things I do care about:
- patient's getting better (no brainer; use whatever technique as long as patient is getting better)
- perceived benefit by the patient (I had a patient this week that was getting better but didn't perceive benefit of PT. Discussed with PT who agreed. Discharged!)
- utilization of resources (I've had 2-3 patients in the past week who saw me after 12 weeks of therapy with no improvement. Now, they don't have any more visits or money to try different options)-
- clear disregard of restrictions (I had a patient with acute cervical radiculopathy with a PT who was trying cervical manipulations---I wrote no spinal manipulations)

As long as the patient is getting better in an efficient manner...this is the bottom line for me!

 

[RUOkie]

PT's prescribe physical therapy, and noone else. Physician's refer to physical therapy. There is a big difference in knowledge level of a PT in relation to PT vs any physician, regardless of training. If you think it is appropriate for you to request a certain technique then you should also feel it's ok for a PT to request you prescribe a certain medication, or test. It's the same thing.

You are not correct there. In states with direct access that may be true, but according to CMS, the PHYSICIAN prescribes the PT. That is what that plan of care form we have to sign for you is.

I have a very good relationship with the therapists I work with. They are professionals, as am I. When my orders are ignored, I call the PT to find out why. You might be surprised how often the therapist "is too busy to take my call", or is "not available" and then never calls back. Those therapy clinics NEVER get another patient of mine. And I tell them why.

 

[PMR 4 MSK]

PT's prescribe physical therapy, and noone else. Physician's refer to physical therapy. There is a big difference in knowledge level of a PT in relation to PT vs any physician, regardless of training. If you think it is appropriate for you to request a certain technique then you should also feel it's ok for a PT to request you prescribe a certain medication, or test. It's the same thing.

The PT can request anything he wants of me, but if he recommends I prescribe a certain medication, he risks his license. The recommendation of medication other than OTC remains purely in the scope of practice of an MD or DO, and no one else, by law.

You can argue semantics of physicians prescribing PT or referring for it. In the end, the PT has a license and makes their own clinical decisions regarding their portion of the patient's treatment. In my state, and I believe many/most states, the plan requires physician approval. I.e., the PT sees the pt, does their initial assessment and plan, sends it to the doc for signature. Therefore, in the eyes of the law, PT is prescribed by a physician. In reality, I bet less than 1 out of 20 physicians reads the PT note before signing it.

When (not if) PT's have more direct-access to patients, that will change legally, hopefully for the better for everyone involved. In the meanwhile, I will continue to prescribe PT and recommend what I think will likely help the patient. If the PT decides they want to modify that, or needs to change it in the course of treatment, I can't remember the last time I voiced an objection. I'm just trying to provide some guidance.

To just write "PT: Eval and Tx" goes against my training and judgement as a Physiatrist. Which is probably why so many PTs dislike Physiatrists.

 

[PMR2008]

To just write "PT: Eval and Tx" goes against my training and judgement as a Physiatrist. Which is probably why so many PTs dislike Physiatrists.

 

[Fiveoboy11]

You are not correct there. In states with direct access that may be true, but according to CMS, the PHYSICIAN prescribes the PT. That is what that plan of care form we have to sign for you is.

I have a very good relationship with the therapists I work with. They are professionals, as am I. When my orders are ignored, I call the PT to find out why. You might be surprised how often the therapist "is too busy to take my call", or is "not available" and then never calls back. Those therapy clinics NEVER get another patient of mine. And I tell them why.

State law dictates and governs physical therapy, not CMS. A insurance requiring a physician to sign a POC to reimburse does not mean the physician is prescribing. Any state where PT has direct access (and rightfully so) the PT has full authority, in other states the PT still prescribes PT but is required by law to follow physician directives. Obviously physicians do have referral authority, and can big time the PT by "NEVER" sending them a patient again. Talk about abuse.

**Do not get me wrong, I always follow medical precautions to the letter, and respect/consider any suggestions or things written on a script. PT's can by law do whatever they feel is best for the patient, regardless of what a physician/script says (in direct access states). Trust me this is in the best interest of the patient. If you were a PT you would understand based on the poor recommendations written on scripts and repeated demonstration of lack of knowledge from referring providers.

The physician signing the POC is only to allow reimbursement, it is a way for insurance companies to save money. PT's do not need your squiggle to do their job. This is outdated and baseless.

I used to think only chiropractors thought they practiced and prescribed physical therapy. How stupid of me...

 

[jesspt]

Fozzy:

Open line of communication is key and mutual respect seems to be the underlying theme!

Well said!

- clear disregard of restrictions (I had a patient with acute cervical radiculopathy with a PT who was trying cervical manipulations---I wrote no spinal manipulations)

Uh, ....wow. Not sure how anyone could justify the choice of that intervention.

PMR 4 MSK:

The PT can request anything he wants of me, but if he recommends I prescribe a certain medication, he risks his license. The recommendation of medication other than OTC remains purely in the scope of practice of an MD or DO, and no one else, by law.

You can argue semantics of physicians prescribing PT or referring for it. In the end, the PT has a license and makes their own clinical decisions regarding their portion of the patient's treatment. In my state, and I believe many/most states, the plan requires physician approval. I.e., the PT sees the pt, does their initial assessment and plan, sends it to the doc for signature. Therefore, in the eyes of the law, PT is prescribed by a physician. In reality, I bet less than 1 out of 20 physicians reads the PT note before signing it.

When (not if) PT's have more direct-access to patients, that will change legally, hopefully for the better for everyone involved. In the meanwhile, I will continue to prescribe PT and recommend what I think will likely help the patient. If the PT decides they want to modify that, or needs to change it in the course of treatment, I can't remember the last time I voiced an objection. I'm just trying to provide some guidance.

To just write "PT: Eval and Tx" goes against my training and judgement as a Physiatrist. Which is probably why so many PTs dislike Physiatrists.

Nice post. I'll reiterate what was posted in the thread that Fozzy alluded to earlier. As a PT who desires a collaborative relationship with his patients' physicians, I welcome all pertinent info that you uncover during your musculoskeletal work-up of the patient, as well as any recommendations you might have.

And, I don't think that as a rule, PTs dislike physiatrists, but as you may have noticed, there can occasionally be some tension, which from the PTs part probably stems from some of the growing pains happening within our own profession. The push for unfettered Direct Access (outside of the military), and the mandate to change the entry-level degree to a clinical Doctorate has caused some uncertain footing as to where we are in the current healthcare landscape.

For my part, I agree with you that once Direct Access becomes a commonplace reality, rather than the rarity it currently is, patients will benefit. And in particular, patients with LBP will gain advantageous access to a provider that can be of great assistance to them.

 

[Jitter Bug]

Sounds like fiveboy you may live in a direct access state that allows PTs' to eval and treat patients without a physician's prescription. This is not the case in my state.

As for respecting the knowledge base, it goes both ways, which is the professional courtesy part. If I ask a PT to spend 10-12 sessions playing Earth Wind & Fire and whacking my patients sore back with goose feathers, I would expect a phone call asking me to clarify why I chose this particular method, and would I be open to adding other evidence based interventions? And if I rudely insist its only gonna be EW&F and feathers, I would expect that PT to decline my script and ask me to take my business elsewhere.

 

[jesspt]

State law dictates and governs physical therapy, not CMS. A insurance requiring a physician to sign a POC to reimburse does not mean the physician is prescribing. Any state where PT has direct access (and rightfully so) the PT has full authority, in other states the PT still prescribes PT but is required by law to follow physician directives. Obviously physicians do have referral authority, and can big time the PT by "NEVER" sending them a patient again. Talk about abuse.

**Do not get me wrong, I always follow medical precautions to the letter, and respect/consider any suggestions or things written on a script. PT's can by law do whatever they feel is best for the patient, regardless of what a physician/script says (in direct access states). Trust me this is in the best interest of the patient. If you were a PT you would understand based on the poor recommendations written on scripts and repeated demonstration of lack of knowledge from referring providers.

The physician signing the POC is only to allow reimbursement, it is a way for insurance companies to save money. PT's do not need your squiggle to do their job. This is outdated and baseless.

I used to think only chiropractors thought they practiced and prescribed physical therapy. How stupid of me...

Five, I'm not sure you're really helping your argument here. Not sure if your posts are a manifestation of insecurity, or if you have had multiple negative experiences with referral sources, but you're doing a really good job of letting the anger of your posts interfere with your attempts to make a point.

And, when I practiced in Washington DC, which has direct access, I didn't prescribe "PT" either. I prescribed therapeutic exercise, manual therapy, functional activity, etc. Physical therapy is a profession, practiced by professionals, not a singular modality or intervention. To refer to it as otherwise, particularly on this forum perpetuates misconceptions that I'd rather see disappear. Such as patients "failing PT." They didn't fail PT, but they may have failed lumbar stabilization and ultrasound and instead would have benefited from repeated end-range loading of the spine, a la Mechanical Diagnosis and Treatment (McKenzie). Your perseveration on semantics is getting a little tired.

 

[jesspt]

Sounds like fiveboy you may live in a direct access state that allows PTs' to eval and treat patients without a physician's prescription. This is not the case in my state.

As for respecting the knowledge base, it goes both ways, which is the professional courtesy part. If I ask a PT to spend 10-12 sessions playing Earth Wind & Fire and whacking my patients sore back with goose feathers, I would expect a phone call asking me to clarify why I chose this particular method, and would I be open to adding other evidence based interventions? And if I rudely insist its only gonna be EW&F and feathers, I would expect that PT to decline my script and ask me to take my business elsewhere.

Ha!

 

[PMR2008]

For my part, I agree with you that once Direct Access becomes a commonplace reality, rather than the rarity it currently is, patients will benefit. And in particular, patients with LBP will gain advantageous access to a provider that can be of great assistance to them.

Sorry for my ignorance but what is the proof for that statement?

 

[jesspt]

Sorry for my ignorance but what is the proof for that statement?

For which part of that statement would you like proof?

 

[ghost dog]

I get the vibe that this is the prevailing opinion by the physicians who are posting on this thread. My concern is just what is that "wavelength." There are A LOT of physicans in my area who are caring for patients with musculoskeletal complaints who may have a good idea of how to manage those patients medically, but have little idea of how to provide rehabilitation for them. I am certainly not implicating those who are participating in this forum, but I think with some reflection on your peers, many of you will agree with me.

I still get an incredibly high number of prescriptions requesting (and I use this term liberally, as I am sure that those who are putting in down on paper are expecting it to be done) US, e-stim, heat. Several times a year I will get prescriptions for myofascial release or some other more "fringe" intervention. Many times the prescription for these passive treatments is carried to me by a patient who has chronic symptoms and are exhibiting huge amounts of fear-avoidance behaviors and have fallen into a reliance on passive coping strategies as they attempt to manage their symptoms. So, here I am, on the raggedy edge. Should I blindy follow the prescription handed to me by the patient (full of treatments that are nearly certain to leave this patient's symptoms unchanged at best, or possibly leave them worse), or do I use the results of my exam, the current literature relevant to the patient's clinical signs and symptoms, and the patient's input to guide me? I invariably side with my responsibility to my patient, and my concsience, and provide them with the treatment that seems to be the best for their given situation, trying to use research and reason, when and where it exists. Have I taken to much "liberty" here? Do I expect to much "latitude"?

I applaud the posters on this forum for your attempt to communicate with the therapists to whom you refer patients. Establishing a real professional and collegial relationship with local PTs should enhance your practice and your patient outcomes. There are a great many PTs who stay abreast of the relevant literature, and, if they have omitted some treatment that you wrote on a prescription, did so because when the research, their clinical experience, and the patient's presentation (including their expectation, values and preferences) all collided the day the PT treated them, that treatment didn't seem to be in the bets interest of getting the patient better. Nothing more, nothing less, and certainly nothing malicious.

What is your approach to patients with significant pain amplification behavior?

I see patients who have seen physios for months at a time and it appears that I always need to reinforce the hurt versus harm concept. I'm sure it only appears that way (i.e. this has been discussed previously).

I can't help thinking that some of these patients present this way , in part, due to prolonged inappropriate treatment with passive therapeutic modalities.

 

[axm397]

We have 14 therapists at 5 locations in my group. I know all 14 of them and what they like to treat, their training, and their personality/hobbies. I have lunch with my PTs at least 1-2 times a month. I talk to them and email them and vice versa weekly.

The PTs I refer to outside of my group have my cell phone number and email address. I try to serve as a "match maker" to match the right therapist to the right patient both in terms of skillset and personality. The outside PTs refer me patients and I refer them patients. Some of the PTs have seen me themselves as patients. My relationship with the PTs has been one of the most important factors in making me a successful Physiatrist with a flourishing practice.

I really like McKenzie for radiculopathy, which is 70-80% of what I see in clinic. I know and regularly converse with the 4 diplomate level McKenzie therapists in my area and will be giving a talk at their next diplomate only conference which attracts therapists from all over the country.

I also refer to manual therapists (Paris, etc), pelvic therapists, chiropractors (that I have personally met and vetted), and acupuncturists. I do sometimes prescribe certain modalities (ionto, ultrasound, kinesiotape, aquatherapy, etc) depending on the pathology.

My job is to try to get people better without heavily medicating them, injecting every joint they have, or having to refer them to surgery. Physical therapy is the first line of therapy to achieve this goal and 90+% of my patients get referred to PT. I am consistently one of the top 3 referrers to PT in my group and I'm proud of that because I think it is the best utilization of limited resources to treat pain.

 

[Fiveoboy11]

Five, I'm not sure you're really helping your argument here. Not sure if your posts are a manifestation of insecurity, or if you have had multiple negative experiences with referral sources, but you're doing a really good job of letting the anger of your posts interfere with your attempts to make a point.

And, when I practiced in Washington DC, which has direct access, I didn't prescribe "PT" either. I prescribed therapeutic exercise, manual therapy, functional activity, etc. Physical therapy is a profession, practiced by professionals, not a singular modality or intervention. To refer to it as otherwise, particularly on this forum perpetuates misconceptions that I'd rather see disappear. Such as patients "failing PT." They didn't fail PT, but they may have failed lumbar stabilization and ultrasound and instead would have benefited from repeated end-range loading of the spine, a la Mechanical Diagnosis and Treatment (McKenzie). Your perseveration on semantics is getting a little tired.

Not sure how I came across as angry or insecure, perhaps that is based on your interpretation of my previous postings and has nothing to do with these. I really haven't had any negative interactions with referral sources, I believe they have been quite happy everywhere I've been.

I have been using the words practice and prescribe synonomously, so if there is confusion that is probably the basis. Referring and prescribing are not the same terms to me which might be the case with some other posters.

 

[jesspt]

What is your approach to patients with significant pain amplification behavior?

I see patients who have seen physios for months at a time and it appears that I always need to reinforce the hurt versus harm concept. I'm sure it only appears that way (i.e. this has been discussed previously).

I can't help thinking that some of these patients present this way , in part, due to prolonged inappropriate treatment with passive therapeutic modalities.

These patients can be difficult to treat, and I think the inital instinct for some therapists is to address the patient's report of pain with modalities, when in reality this probably encourages the patient's reliance on passive coping strategies, and further entrenches them in their fear-avoidance behaviors.

I usually try to educate the patient about their pain from the perspective of the pain neuromatrix as developed by Melzak:

http://www.ipcoregon.com/pdf/pain_and_the_neuromatrix_in_the_brain.pdf

We do have some evidence that in some populations, a deeper education regarding the neurophysiology of pain can positively effect our patients:

This paper represents the bullet points that I discuss with patients:

http://docserver.ingentaconnect.com...ser&checksum=62C030DF6AE0AC973550CA956BF85BB7

And here are some papers which show some positive effects from pain physiology education:

http://www.somasimple.com/pdf_files/evidence_cognitive_physical.pdf

http://svc019.wic048p.server-web.com/ajp/vol_48/4/AustJPhysiotherv48i4Moseley.pdf

http://www.rehab.research.va.gov/jour/11/481/pdf/vanoosterwijck.pdf

 

[RUOkie]

Obviously physicians do have referral authority, and can big time the PT by "NEVER" sending them a patient again. Talk about abuse.
..

So, if I do not refer to a provider who communicates with me, that is ABUSE? I am the same way with other physicians! I treat the professionals I work with like they are professionals. I expect the same in return. If I do not get that, I find other people to work with.

Like AXM, the therapists I work with have my cell phone #, and I will leave a patient room to take a call from them. Just like I do with physicians (or psychologists etc.).

Good communication is key when dealing with this patient population. I see a ton of work comp, often with delayed recovery, so if we are not on the same page, the patient (or sometimes the employer) loses.

 

[Fiveoboy11]

So, if I do not refer to a provider who communicates with me, that is ABUSE? I am the same way with other physicians! I treat the professionals I work with like they are professionals. I expect the same in return. If I do not get that, I find other people to work with.

Like AXM, the therapists I work with have my cell phone #, and I will leave a patient room to take a call from them. Just like I do with physicians (or psychologists etc.).

Good communication is key when dealing with this patient population. I see a ton of work comp, often with delayed recovery, so if we are not on the same page, the patient (or sometimes the employer) loses.

I agree with you.. physician and PT collaboration is a great thing, and should require excellent communication. I recognize the amount of potential there is with better relationships between PT's and physician's. The sticking point is physician's (especially non MSK) writing specific intereventions on a script and expecting us to follow them when they are often inappropriate or not beneficial to the patient. I prefer to spend my time with the patient to help them as opposed to making phone calls. Communication is via the POC/eval faxed to the physician, it is not sent to be signed IMO. I provide detailed info and assessments on my paperwork so the communication is there.

 

[fozzy40]

I prefer to spend my time with the patient to help them as opposed to making phone calls. Communication is via the POC/eval faxed to the physician, it is not sent to be signed IMO. I provide detailed info and assessments on my paperwork so the communication is there.

Not a great way to help patients that you want to want to spend time with.

 

[Gauss]

Back to topic
PT reimbursement and # of visits is being destroyed in my area. For state funded patients they get 1 visit, basically an eval, that's it. For elderly patients that need guidance, encouragement, and progress much slower this is killing my practice. I spend an entire visit or 2 showing them exercises and reviewing pictoral handouts. Even getting videos online and running them in the waiting room with the help of some PT's. But I'm getting hammered into an impossible position - inject everyone and everything and medicate because no one will pay for PT but they'll pay for hydrocodone and corticosteroids.

 

[jesspt]

Back to topic
PT reimbursement and # of visits is being destroyed in my area. For state funded patients they get 1 visit, basically an eval, that's it. For elderly patients that need guidance, encouragement, and progress much slower this is killing my practice. I spend an entire visit or 2 showing them exercises and reviewing pictoral handouts. Even getting videos online and running them in the waiting room with the help of some PT's. But I'm getting hammered into an impossible position - inject everyone and everything and medicate because no one will pay for PT but they'll pay for hydrocodone and corticosteroids.

PT reimbursement is decreasing all over, but I've never heard of something this egregious. Do any private PT practices even take Medicaid/public aide around you?

 

[jesspt]

So, if I do not refer to a provider who communicates with me, that is ABUSE? I am the same way with other physicians! I treat the professionals I work with like they are professionals. I expect the same in return. If I do not get that, I find other people to work with.

Like AXM, the therapists I work with have my cell phone #, and I will leave a patient room to take a call from them. Just like I do with physicians (or psychologists etc.).

Good communication is key when dealing with this patient population. I see a ton of work comp, often with delayed recovery, so if we are not on the same page, the patient (or sometimes the employer) loses.

Your stance on this seems totally reasonable to me. When previous patients of mine call and ask for recommendations re: which physician to see for their condition, I certainly suggest that they see an MD/DO that I have had previous positive experiences with.

 

[SSdoc33]

Back to topic
PT reimbursement and # of visits is being destroyed in my area. For state funded patients they get 1 visit, basically an eval, that's it. For elderly patients that need guidance, encouragement, and progress much slower this is killing my practice. I spend an entire visit or 2 showing them exercises and reviewing pictoral handouts. Even getting videos online and running them in the waiting room with the help of some PT's. But I'm getting hammered into an impossible position - inject everyone and everything and medicate because no one will pay for PT but they'll pay for hydrocodone and corticosteroids.

id say a good 1/3 to 1/2 of the patients i send to PT stop going because they state they cant afford the copays

 

[jesspt]

id say a good 1/3 to 1/2 of the patients i send to PT stop going because they state they cant afford the copays

The insurance companies will be happy to hear that the copayments are having their intended effect.