Is the Nintendo Wii Skilled Physical Therapy?

You can go buy the Nintendo Wii Gaming System from Circuit City for $249.99.

I haven't done this but I could buy the Nintendo Wii Gaming System and use it in my physical therapy clinic billing patients for Therapeutic Activities (97530) or Therapeutic Exercise (97110) all day long.

You could also buy the Wii Fit Balance Board from Circuit City for $89.99 and put that in your physical therapy clinic, too.

Apparently, many physical and occupational clinics have done just that.

"Herrin Hospital in southern Illinois, about 100 miles southeast of St. Louis, bought a Wii system for rehab patients late last year.

At Walter Reed Army Medical Center, the (Wii) therapy is well-suited to patients injured during combat in Iraq, said Lt. Col. Stephanie Daugherty, Walter Reed's chief of occupational therapy."

I live in a resort community on the west coast of Florida and many of my retired patients would love to come to me for rehabilitation focused around their tennis or golf lifestyles.

Some physical therapists have declared that Wii is inappropriate in the physical therapy clinic,. Larry Benz is a physical therapist with a large following who has posted on multiple occasions at MyPhysicalTherapySpace.com about his displeasure with the Wii.

My position on the Wii (and technology in physical therapy in general) is this: Does it help the patient?

If technology (including the Wii) is good for the patient then we should consider its use.

I have not ready Larry Benz' every post so maybe he has already brought this next point up.

Is Wii skilled therapy?

Every third-party payer requires physical therapy be skilled physical therapy. Most insurance contracts have a 'boilerplate' section that mentions this.

Only Medicare has police powers so we usually just talk about Medicare requiring evidence of skilled therapy in the daily Treatment Encounter Notes.

Transmittal 88 has a specific definition of skilled therapy, as follows:

"Services must not only be provided by the qualified professional or qualified personnel, but they must require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently. A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period." (page 25)

This next section is repetitive but bears on the Wii issue...

"Services provided by aides, even if under the supervision of a therapist, are not therapy services and are not covered by Medicare. Although an aide may help the therapist by
providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services." (page 42)

What is missing from the Wii debate is the diagnosis.

What is the specific impairment, addressed by the Wii, that is addressed that when treated, will significantly improve patient function?

Also from Transmittal 88...

"A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant."(page 27)

To paraphrase Hippocrates, "First, a physical therapy diagnosis".

Sahrmann wrote the book on diagnosis

Diagnosis and Treatment of Movement System Impairments by Shirley Sahrmann, PhD, PT, FAPTA came out in 2002 and I bought the book, I read the book and I changed how I practiced because of the book.

Now, in 2008, I am slowly re-reading the book.

I am going out of order, chapter by chapter. I read chapter 4 (the hip) first and now I'm back to the Introduction.

Tonight, I've come across a passage that, even though I don't remember hi-lighting in 2002, tremendously changed my life.

If you'll permit, I'll share it with you now...

"A standardized examination format is used to identify the Directional Susceptibility to Movement (DSM) and the factors that contribute to the presence of a dysfunction" (p.4)

When I took her physical therapy continuing education course in 2003 I saw her use her standardized examination format.

Dr. Sahrmann's tests are easy to learn, reproducible and reliable.

My only concern with her approach is that she assesses pain.

Dr. Sahrmann states the following:

"The (Movement Impairment) syndromes are named for the alignment, stress or movement direction that most consistently produces pain." (p. 74)

I wonder if physical therapy can move forward if we continue to assess pain?

Dr. Sahrmann influenced my career because I went on to develop a standardized assessment system that uses repetitive, corrective exercises to influence and improve 'regional musculoskeletal disorders'.

I've detailed the standardized approach at Physical-Therapy-Videos.com .

Nevertheless, Diagnosis and Treatment of Movement System Impairments by Shirley Sahrmann brought me a watershed moment in my career and my professional growth.

I encourage every physical therapist and physical therapist assistant to buy and read a copy of Dr. Sahrmann's book.



Take her course and watch her diagnose her patient right in front of you.

Nothing will give you greater confidence in pursuing physical therapy diagnosis than watching the one who wrote the book.