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Raising the Bar in Rehab

Functional Measurements

Published September 26, 2013 3:24 PM by Lisa Mueller

At the PT 2013 conference earlier this summer, one of the speakers encouraged physical therapy programs to transition away from education on passive modalities and objective measurements such as range of motion or manual muscle testing to instead focus on functional limitations and progress towards functional goals.

I've thought a lot about this idea since hearing it and gone through a few "phases" of acceptance. At first, I was in complete agreement. In most of my patient experiences, I've been able to track a patient's progress with gross strength and range-of-motion measurements compared to the exact goniometer alignment and measurement of a patient's range I learned about in school. There are times with a post-operative patient when that quantitative data is needed, but in most cases I focus on the functional impairments. I use passive modalities mostly for pain control, but have found most effective treatments using exercise and manual techniques. So overall, I was happy to hear that other practitioners held a similar opinion to my own and expressed it at the conference.

The second part, as I'm experiencing now nearly three months after hearing this proposal, is my curiosity about how these changes will be implemented. Passive modalities have been a part of physical therapy curriculums for decades. How can we transition away from that? My thought is that teaching content like modalities is either an all or none topic; is there any gray area to teaching only part of the material?

I give a lot of credit to the people involved with establishing the content for physical therapy programs. It cannot be an easy task to sort through the latest research while also balancing that with traditional practice techniques. I can't imagine being the person to say, "Okay, we aren't going to teach anything about ultrasound this year" because it seems like such a "basic" to being a physical therapist. I'm sure other content was phased out in PT programs during the years before I was a student, and I know educational programs in the future will continue to focus on the most relevant components of being a physical therapist.

What do you think? Is it important to continue teaching students about passive modalities, range of motion and manual muscle testing? Have you experienced changes in PT program curriculum during your years of practice? If you are an experienced clinician, are you ever surprised by what students are learning?

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Treatment of lymphedema falls into the Medicare definition of services covered that are "reasonable and necessary for the treatment of illness or injury", which is not the same as "rehabilitation". Different outcome measures may be necessary from the usual functional disability measures.

Section 1862(a)(1) of the Social Security Act (the Act) states that payment may be made under Medicare Part A or Part B only for items and services that are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". In other words, an item or service must be reasonable and necessary for:

diagnosis of illness or injury, OR

treatment of illness or injury, OR

improving the function of a malformed body member.

The definition of covered "Medical and Other Health Services" is provided in Section 1861(s) of the Act, and I believe that there is a one-to-one correspondence between the covered medical objective above and the provider of the provided service below:

"physician's services" §1861(s)(1), OR

"services and supplies ... furnished as an incident to a physician's professional service..." §1861(s)(2)(A), OR

"outpatient physical therapy services and outpatient occupational therapy services" §1861(s)(2)(D).

It is my opinion that there is a qualitative difference between services provided for the "treatment of illness" and services provided for "improving ... function". This difference seems to have escaped CMS when they included all physical therapy (PT) and occupational therapy (OT) services under rehabilitation rules, including notably the therapy caps and exceptions rules. [There was a brief period in the early 2000's when separate lymphedema treatment LCDs existed, separate from the outpatient therapy LCDs, but they have since been retired.]

The above blurring of any differentiation between treatment of illness and improving function of a malformed body member seems to be leading to another blow to lymphedema treatment where therapy reimbursement will be shifting from a "services provided" to an "functional outcomes achieved" schema, and the outcome measures are, so far, all functional disability measures. Functional data are being collected in 2013 in preparation for reimbursement change in 2014.

Current research is leading to the conclusion that it is far better to detect lymphedema as early as possible and intervene to prevent or delay the swelling and destructive tissue changes, than to wait until there is appreciable measurable swelling or disability. Reference Stout's Prospective Surveillance Model which uses a 3% volume change threshold for intervention with compression sleeves and Zimmermann, who uses MLD on all post-mastectomy patients from day 2 to prevent lymphedema.

Robert Weiss, Lymphedema - Patient Advocate October 16, 2013 6:03 AM
Porter Ranch CA

Great point, Dean!  Thank you for sharing!

Lisa Mueller September 30, 2013 7:38 PM

I remember back when dinosaurs roamed the earth and I was a PT student, the excellent professor teaching modalities made it perfectly clear that they were adjuncts to treatment and not a treatment in and of themselves. I think your assessment of them is spot on, useful in certain circumstances, but not the be-all-and-end-all.

As for muscle testing and goniometry, I do think those skills are important to teach. I have done "functional" assessments for more than the second half of my career, but I also still do muscle testing and goniometry to determine where specific deficits are that impair the function. OK, someone has an unsteady gait, why? Are their hip abductors weak? Gastrocs shortened from a lifetime of high heels? Postural muscles so weak from minimal upright activity? Those objective measures give me what I need to address to achieve those functional goals.

I've watched new grads (here in the UK) struggle with addressing functional issues because they have already transitioned away from objective measures. They examples of unsteady gait I used above was one conversation I had with a new grad here. So no, I don't think we should stop teaching those things. To me it is tossing out the baby with the bathwater.

Dean Metz September 27, 2013 5:44 AM

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