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September 2000 District Meeting Recap
By Tom DeFranco
At the September district meeting, we had the privilege of hearing
from two guest speakers. The first speaker was Bob Niklewicz from the
California Chapter’s Third Party Payor Committee. Bob presented
information about the resources available to help promote physical
therapy to the health care consumers. The second speaker was Dr. Joel
Saal from the SOAR medical group. Dr. Saal presented Intra-Discal
Electrothermal Annuloplasty (IDET). IDET is a treatment for chronic
low back pain.
Bob Niklewicz discussed in detail the issues that face the physical
therapy profession in the HMO arena. HMO’s continue to adversely
affect reimbursement for P.T. services. Unfortunately, a negative
cycle is developing between the type of services provided by P.T. and
the 3rd party payer’s perception of need/value of these
services. Here is what’s happening.
Bob has seen the above scenario play out in different areas of the state.
The Third Party payor committee has identified the health care
consumer as the key to break this viscous cycle. It is the consumer
who drives the type of health care services that 3rd party payers
offer, but many consumers still do not know what physical therapists
can do for them. By informing the public of the type of services
physical therapist’s provide, the chapter hopes to increase the
demand and value of physical therapy services. Therefore, the chapter
has designed an advertising plan available to clinicians to help
inform the consumer about physical therapy. The plan includes the use
of newspaper advertising and brochures to spark consumer interest.
Furthermore, as the chapter receives response to the advertisements,
they will be keeping a database, to keep the interested consumers
informed of future information/developments regarding the importance
of physical therapy in heath care. For more information, call the
California Chapter APTA at (800) 743-2782
Our second speaker, Dr. Joel Saal reviewed the history behind the
treatment of chronic back pain before discussing in detail the IDET
procedure. It is estimated that up to 8 million people in the U.S.
suffer from discogenic chronic low back pain. One half of these
individuals are disabled. There are many treatment options for these
individuals: Passive P.T., Chiropractic, Exercise P.T., Implanted pumps/stimulators,
Medications and psychological support. The only treatment above that
shows significant efficacy was Exercise physical therapy, but for
only 30%. The other 70% of chronic low back pain patients found
insignificant relief or suffered other complications/side effects
with these treatments. When these approaches fail, surgical
intervention is considered. Discectomy, percutaneous nucleotomy, and
lumbar fusion have all been used in attempts to treat low back pain.
Discectomy and nucleotomy significantly reduce extremity pain, but
not the low back pain. With a fusion (if successfully fuses), 70% of
the patients have a 50% improvement in pain. Complications of surgery
include nerve root damage, non fusion, and other complications that
come with any surgical procedure. When you combine the
ineffectiveness of most of these treatments with those unwilling to
have surgery, that leaves many individuals who continue to suffer
disabling low back pain.
Dr. Saal explained that many of these treatments fail because it does
not address the cause of the back pain. Our disc is innervated by
pain receptors in the outer 1/3 of the disc. When we cause trauma to
the disc, the outer 1/3 causes tears, allowing these pain receptors
to grow into the tears. The tears cause micro-instability of the disc
and increases uneven loading of the disc. This activates the pain
receptors in the tears, responding to mechanical and chemical
irritation. According to Dr. Saal, these annular tears can be seen on
MRI and discogram studies.
Dr. Saal uses the IDET procedure because it addresses the problem of
the tears in the disc.
The IDET procedure uses a small flexible catheter, which is inserted
into the disc tears. Heat is then applied through the catheter to the
collagen of the disc. It has been shown that heat shortens collagen
tissue and coagulates free nerve endings. The pain improves due to
increased stability of the disc and coagulation of the pain receptors
from the IDET procedure. IDET studies have shown that 73% of the
patients had significant improvement in low back pain, with a report
of 50% reduction of pain, 50% increase in function.
Physical Therapy’s role in the rehabilitation of the IDET
patient does not start for the first 2 months. This allows proper
return of blood flow and nutrition to the disc. The patient
immediately after the procedure works on walking and minimizing sit
time. At 8 weeks, Physical therapy develops a slow progressing lumbar
stabilization program. The patient can return to recreational
activities after 4 months.
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District Meeting Recap - Hippotherapy
May, 2000
By Debra Gutierrez, PT
Hippotherapy is becoming a more familiar word, but what about the
concept behind the name? Barbara Heine, from the National Center for
Equine Facilitated Therapy in Woodside, was our guest speaker at the
last district meeting in May. She provided background on her facility
and hippotherapy and how it is used therapeutically today.
Barbara is an Australian born physiotherapist who came to the US in
1988 to manage the Center. The Center is a not for profit orgnization
and utilizes the help of some 50-70 volunteers in addition to 11
staff members. Hippotherapy has been used by physical, occupational
and speech therapists for the treatment of impairments and disabilities.
So what is Hippotherapy? As you might guess, it doesn't involve
hippos as the name initially suggests. Hippo is actually Greek for
horse and the backbone of this form of therapy is the placement of
clients on horseback. Treatment at the Center in Woodside is
specifically aimed at the pediatric population, especially for those
children between the ages of 2-8 years old. While older children and
adults may well benefit, other considerations such as safety due the
client / horse weight ratio and fear levels come into play.
The usual diagnoses include cerebral palsy, congenital genetic
disorders and low tone. It has been suggested that children respond
particularly well due to the neural plasticity of the CNS. When
adults are treated, the usual dianoses include multiple sclerosis,
CVA and traumatic brain injury.
The horse is considered a tool of treatment, much like a Physioball.
Each child is assessed for their needs and a horse is chosen that
most closely fits those needs. Horses have a gait pattern that is
similar to that of humans and each horse has its own particular gait
characteristics. It is these characteristics that are chosen for a
particular child. Facilitating the child's pelvic motion via the
horse's motion is at the core of hippotherapy. Pelvic motion can be
modified along any axis for lateral and anterior-posterior pelvic
tilt, as well as rotation. Use of different stirrups and saddles can
also be used to change the pelvic tilt of the client riding the
horse. How the horse is driven can also change the input to the
client. For example, if the horse's pace is slowed, stride length is
increased and an increase in amplitude is achieved. In addition, the
centripedal force created when the horse turns can be used to
facilitate trunk elongation, etc.
Beyond the facilitatory aspects of horseback riding sensory inputs
are incorporated / integrated such as vestibular, visual, olfactory,
proprioceptive, tactile and auditory stimuli that are present because
of the horse as well as the immediate surroundings.
How does someone access the Center? Screening begins with a telephone
interview to rule out absolute contraindiations such as:
1. Weight limit: A rider can be no more than 20% of the horse's total
body weight, i.e. >240 lbs.
2. Autism
3. Less than 30 degrees of hip abduction and external rotation
4. Severe tone at hip internal rotation and adduction
5. Significant behavioral problems
The initial evaluation is 60 minutes, a third of which is on
horseback and is functionally oriented. The majority of treatment is
on the horse with a small pre/post therapy session and reassessments
are done evey 3-6 months. An early short term goal might be change in
trunk control with an expectation of progess towards a more
functional long term goal such as one involving ambulation. Typically
four people and one horse are used for each client. Evaluation costs
$90 and treatment is $115 per 30 minutes. Fifteen to 20% of the
clients are able to bill insurance; the rest pay as they can and fund
raising supplements the cost of providing treatment. Helpful hint:
bill as neuromotor reeducation or therapeutic procedures; don't code
as a modality. There is currently a waiting list of 60 people.
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Summary of SJAPTA district meeting of February 8, 2000
Terry Nordstrom, PT, Professor at Samuel Merritt College of Physical
Therapy came and discussed the continuing evolution of the APTA’s
Guide to Physical Therapy Practice. The purpose of the guide is to
provide a general description of the profession of physical therapy,
standardize terminology and to delineate preferred practice patterns
that will help PT’s enhance the quality of care, improve patient
satisfaction, promote appropriate utilization of health care
services, increase efficiency and reduce unwarranted variation and
promote cost reduction through wellness and prevention.
Terry was quick to point out that the Guide does NOT provide specific
protocols for treatment, nor is it intended to serve as clinical
guidelines. The Guide represents expert consensus and contains
preferred practice patterns describing common sets of management
strategies for select patient diagnostic groups. The Guide describes
the boundaries within which the physical therapist may select any
number of clinical paths, based on a wide variety of factors.
Part One describes who PT’s are and what they do. It lists and
defines the multitude of tests and measures that PT’s use and it
describes the types of interventions PT’s provide. Part Two is
broken down into four preferred practice pattern chapters:
Musculoskeletal, Neuromuscular, Cardiopulmonary and Integumentary.
Within each chapter are specific practice patterns which describe the
elements of patient management: examination, evaluation, diagnosis,
prognosis, intervention (with expected goals), reexamination,
outcomes and criteria for discharge.
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