"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Thursday, December 27, 2007

SIMPLE Describes Low Back Pain

The SIMPLE movements reflect a common problem.

The SIMPLE movements were derived from my observation that many patients in my practice suffered from disordered movement patterns that result from and contribute to lumbar spinal stenosis.

The interesting thing that I noticed after I had started to gather the data was that many patients who had not (yet) developed radiographic evidence of stenosis, nevertheless, displayed many of the same impairments in strength and range of motion as those patients who had a medical diagnosis of spinal stenosis from their physician.

Low back pain is an endpoint and lumbar spinal stenosis is the last step in the degenerative cascade that originates with disordered movements in our earliest years.

Patients present to many practitioners at points along the way to their penultimate point and it is my hope that SIMPLE can be used to describe the physical dimension of those points.

In my naiveté I persist in believing that if we can describe a physical process then we can change it.


At this point I should acknowledge an obvious bias in the SIMPLE system: an exercise bias.

SIMPLE is designed to provide the physical therapist with goals and interventions that are amenable to therapeutic exercise and (to a lesser extent) manual therapy.

This bias is not accidental.

The physical therapy profession is well positioned to lead the public in modern exercise attitudes and in movement awareness. Exercise is very nearly synonymous with the phrase ‘physical therapy’.

The connection between exercise and physical therapy exists, not because of advertising and marketing, but because of a real need and a demand for skilled exercise services.

The connection between exercise and physical therapy is not complete since the association with exercise is ‘flavored’ by athletic trainers, personal trainers, exercise physiologists, aerobics instructors, coaches and fitness gurus.

To control the domain of exercise then physical therapists need to measure movement.
If a physical therapist can tell their patient the exact amount and quality of their existing movement impairment then the physical therapist can prescribe exercise precisely to correct the impairment.

To measure movement physical therapists need simple and precise tools that determine the extent of their patient’s involvement and that can help decide the proper intervention.

In Outpatient Physical Therapy for Musculoskeletal Conditions, Stephanie Carter, PT, PhD says the following:

“It is not known how many people with musculoskeletal conditions actually need physical therapy services, and no criteria exist for making this determination”8

SIMPLE is predicated upon the following assumption:

The presence of impairments (with or without pain) should be the criteria for determining those people who need skilled exercise intervention.

The role of SIMPLE is to help physical therapists measure the presence or the absence of impairments that affect physical function and thereby become better decision-makers and better diagnosticians.

To physical therapists, physical therapy is much more than just exercise.

To physical therapists’ patients, however, physical therapy is just what physical therapists do.

The patient doesn’t know the difference and the patient doesn’t care.

The patient just wants to get better.


Tools for the Tool Box

The SIMPLE system of diagnosis was born as a Medicare compliance program for a Medicare Part B Physical Therapist in Private Practice.

I was the Compliance Officer and I was in the bulls-eye when the Medicare auditors would come knocking (they haven't yet, knock wood).

After surveying the current marketplace I felt that there were not sufficient tools that I could bring back to my staff to help them get to where I thought we needed to be.

At that point in time my main goal was to get a good nights sleep without worrying about a Medicare audit.

I wanted a tool that would enable my physical therapists and physical therapist assistants to become able note writers, goals-setters and intervention selectors without having to memorize all of the Medicare Benefits Policy Manual, Transmittal 63 (~ 45 pages).


The physical therapist's clinical decision-making and critical thinking skills should be focused on patient care, not on how to best write a legal note in the chart.

I developed the SIMPLE system as an answer to this problem.

The SIMPLE system allows the therapist to spend time with the patient collecting data and building the therapeutic relationship. Once data collection is completed selecting interventions and goal setting are automatic.

Diagnosis is the first step in the system that derives naturally from data that is easily obtained using skills familiar to the new graduate as well as the seasoned expert.

Diagnosis is communicated in standardized language that is familiar to the doctor, the nurse, the PTA and to the patient.

The SIMPLE system helps the physical therapist arrive at a diagnosis by measuring a standardized set of movements that reflect the patient’s ability to generate strength and move through a range-of-motion.

SIMPLE tries to capture data about the lower extremities and the lumbar spine.
Physical therapy diagnosis may include other body parts. The final section of Part 1: Clinical Skills describes Supplementary Positions and Measurements that can be used to diagnose other conditions commonly seen in physical therapy practice.

To study the SIMPLE system for free go to www.SimpleScore.com and view the videos.


Physical Therapist Doctor

It's December 27th 2007 and Physical Therapists are required to make physician-level decisions.

Physical therapists are required to determine the Medical Necessity for Physical Therapy as part of the physical therapy plan of care.

This level of decision-making requires a physical therapy diagnosis, assessment of physical impairments, functional limitations, patient co-morbidities and intangibles like motivation and aptitude.

Just like a medical doctor has tools like x-ray, MRI and blood tests to make the diagnosis the physical therapist needs tools to make the physical therapy diagnosis.

To learn how to assess physical impairments in range-of-motion and strength go to www.SimpleScore.com and view treatment videos.


Wednesday, December 19, 2007

You’re Crazy if You’re Not Paranoid

I just sent a note to my staff therapists.

We’re making a Medicare abbreviation list as a reference for anyone who needs to read our charts: therapists, case managers, back office staff or auditors.

The note said the following:

Please include any abbreviations you typically use in your charts for a list for when the Medicare auditors come

Not if, but when.

Because Medicare audits can be random or targeted and because physical therapists don’t fully understand the criteria for targeted audits.

That’s when it’s good to be paranoid.

When Medicare is concerned, it’s good to be paranoid.

Click here for the OIG Compliance Program for Individual and Small Group Physician Practices.

This document will describe the optimal compliance program for small private practice physical therapists.

I did get a little teasing from my peers for my choice of wording in the note.

The teasing was good-natured and the point was taken. Nevertheless, my recommendation is to design your Medicare compliance program with the end firmly in mind.

Design your compliance program as if you anticipate the worst.

At night I sleep well because in the daytime, at work, I’m paranoid.

Paranoia is a disturbed thought process characterized by excessive anxiety or fear, often to the point of irrationality and delusion. (Wikipedia, Web Accessed 11/30/07)

While these personality qualities are dysfunctional when applied to social relationships they are essential when applied to the mindset of your corporate Medicare compliance officer.

Create an abbreviation list. Mine is posted on this blog as 'Abbreviation List'.

Find other, creative ways to make your organization Medicare compliant. Make it easy for the Medicare auditor to give you a passing grade.

A little paranoia won’t destroy you.

It might save you.

Tuesday, December 18, 2007

How to use the OPTIMAL scale

This video demonstrates the OPTIMAL scale for the initial step in physical therapy diagnosis.

If you don't have written copyright permission to use the OPTIMAL (available for free from the APTA here)then you can use any other functional scale you like. You can even make up your own.

The OPTIMAL is my preference because it is 'recommended' by Medicare. Also, the psychometric properties of the OPTIMAL have been described, including descriptive statistics, measures of reliability, validity and responsiveness. Read the full text article here

Once you have the patient-identified functional limitations you can formulate your clinical hypotheses.

You take measurements in order to support or refute your hypothesis.

You design your plan of care based upon the measured impairments you discover in the course of your evaluation.

You re-measure the impairments to assess progress.

Ultimately, you re-measure the functional limitations (using the OPTIMAL).

The second OPTIMAL serves as a test of your original hypothesis.

Visit www.SimpleScore.com for video demonstrations of simple ways to measure common impairments in ROM and strength.

Tuesday, December 11, 2007

How to Diagnose Rotator Cuff Weakness

View the video to assess rotator cuff weakness. Note that your findings must correlate with the patient-stated functional limitation (eg: cannot raise the involved arm over the head).

The patient may also identify a disability, namely the inability to engage in work or play as a result of the functional limitation.

Please forgive the math error at the end of the video - I was a little nervous.


Free Tutorial

Get free stuff at BulletproofPT.com

Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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