Physiotherapy and Rehabilitation Guidelines
for the Chiropractic ProfessionThis section was compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
|
|
Conditions That Respond | Alternative Medicine Approaches to Disease |
NOTE: This article was copied with permission from the ACRB website in the late 90's, and was reformatted to make it easier to read.
Please note that some of the CPT codes mentioned are out of date now. No attempt has been made to re-write (or update) Dr. Christensen's article to keep it up-to-date.
FROM: The Council on Chiropractic Physiological Therapeutics and Rehabilitation
The Voice & Strength of Chiropractic
By K.D. Christensen, DC, CCSP, DACRB, President
K.D. Christensen, DC is president of the ACA Council on Chiropractic Physiological Therapeutics and Rehabilitation and practices in the state of Washington as director of the Sports Medicine & Rehab Clinic. As a rehabilitation and sports medicine consultant, Dr. Christensen is a frequent speaker at chiropractic conventions. Dr. Christensen is a team physician and consultant to high school and university athletic programs, and himself participated in college athletics. He is currently a postgraduate faculty member at numerous chiropractic colleges and is the author of many publications and texts encompassing musculoskeletal rehabilitation and nutrition.
In the June 1975 edition of the ACA Journal of Chiropractic, the ACA Council on Physiological Therapeutics published perhaps the first "Physiotherapy Guidelines for the Chiropractic Profession." These guidelines have been revisited by the various chiropractic college physiotherapy departments at the request of the ACA Council on Chiropractic Physiological Therapeutics and Rehabilitation.
Introduction
In the 1993 ACA-published text, Applied Physiotherapy, Richard C. Schafer, DC, FICC and Paul Jaskoviak, DC, DACAN, CCSP, FICC write:"Chiropractic physiologic therapeutics encompasses the diagnosis and treatment of disorders of the body, using the natural forces of healing such as air, cold, electricity, rest, exercise, traction, heat, light, massage, water and other forces of nature." [2]
The word "physiotherapy" generally is considered to be a shortened form for physiological therapeutics: treatment by physical or mechanical means. Taber's Cyclopedic Medical Dictionary defines physical therapy as the application of specific modalities, including rehabilitative procedures, concerning the restoration of function and prevention of disability following disease, injury or loss of a body part? The phrase is also to be considered synonymous with the term "adjunctive therapy."'
History
The application of physiological therapeutics in chiropractic possibly began with D.D. Palmer as early as 1886 with his practice of "magnetic manipulation" and the 1896 beginning of the first chiropractic school, named the Palmer School of Magnetic Cure. Peterson reports this so-called "magnetic manipulation" involved the practice of massage. [4]
The application of physiological therapeutics in chiropractic was firmly established at the National College of Chiropractic in 1914. [2] Physical therapy and the many modalities we know today did not become generally accepted by the allopathic medical community at large until 1914-1918, when their use was demanded by the armed services during World War 1.
Wells describes production of intersegmental traction tables by the Spinalator Company for the chiropractic profession as early as 1937 [4] . Logan College of Chiropractic utilized early versions of today's electrotherapy equipment, including the "Polysine Generator" and the "Lightning Electro-Therapy Kit." [2]
Photographs of the B.J. Palmer Clinic in 1945 revealed a large rehabilitation department that was extensively equipped with all the various active high-tech exercise equipment of the day. [2] This included the use of various cycles, stretching mats, parallel bars, proprioception systems and variable resistance exercise devices for all parts of the body Today, Palmer College of Chiropractic is the first college to sponsor a three-year residency program in rehabilitation which is patterned after the popular radiology residency programs throughout the profession.
Table 1 - Treatment Stages & Times of Modality-Procedures
* Chronic recurrent episodes are treated as acute.
Stages of Episode Time Course Acute Acute is 0-6 weeks Stage 1-Acute Inflammation 2-3 days Stage 2-Repair-Regeneration 4-6 weeks Subacute week 7-12 Stage 3-Remodeling-Rehabilitation Stage 4 Rehabilitation Chronic Over 12 weeks Stage 5-Chronic
The Above assumes no complications including obesity; systemic disorders; multiple Injuries; Increased age; noncompliance to care; re-injury or aggravation; patient self-treating or in treatment with others; pre-existence of structural or degenerative dysfunction; psychological disorder/dysfunction medications.
Table 2 - Physiotherapy-Rehab Guidelines
Modality-Procedure Treatment Stage
(Low-High)Treatment Time Range Cryotherapy 1,2,3,4 5-20 minutes Ice massage 1,2,3,4 2-5 minutes Heat-superficial Infrared heat light 2*,3,4 10-20 minutes Hot packs 2*,3,4 10-20 minutes Paraffin 2*,3,4 7-10 dips 10-20-minutes Hydrotherapy 2*,3,4 10-30 minutes Heat--deep Continuous Ultrasound 2,3,4 5-10 minutes Pulsed Ultrasound 2,3,4 2-8 minutes Microwave Diathermy 2,3,4 5-30 minutes Shortwave Diathermy 2,3,4 10-30 minutes EMS Subsensory stimulation 1,2,3,4 none established Sensory stimulation 1,2,3,4 10-30 minutes TENS 1,2,3,4 Variable Muscle stimulator 1,2,3,4 10-30 minutes Motor stimulation 2*,3,4 10-30 minutes Mechanical Vibration 2*,3,4 2-10 minutes Traction (in-office) Continuous 1 *,2,3,4 1-20 minutes Intermittent 1*,2,3,4 1-20 minutes Ambulatory 1*,2,3,4 1-30 minutes Intersegmental 1*,2,3,4 1-10 minutes Flexion-distraction 1*,2,3,4 by technique Extension Compression 1*,2,3,4 by technique Massage 1*,2,3,4 5-15 minutes* Myofascial Release 1*,2,3,4 by technique Trigger Point Therapy 1*,2,3,4 by technique Exercise (in-office) Passive 1*,2,3,4 5-30 minutes Active 1*,2,3,4 15-90 minutes Work Hardening 4 2-8 hours Activities of Daily Living
(i.e., Back School)1,2,3,4 15-60 minutes Bedrest 1 0-2 days Biofeedback (in-office) Muscle Re-education 3,4 5-10 minutes Relaxation/Pain Reduction 4,5 20-30 minutes Bracing 1,2,3,4 none established * Physcian discretion
Guideline Development
In February 1995, the ACA Council on Chiropractic Physiological Therapeutics and Rehabilitation invited all Chiropractic Council on Education (CCE) college physiotherapy departments to attend a conference which was hosted at Western States Chiropractic College. Each college was given the opportunity to send one representative. Additionally, a private practice chiropractor and a physical therapist were invited to attend.
The initial conference group consisted of the following individuals: Kim D. Christensen, DC, DACRB, CCSP, council president; Paul Hetrick, DC, RCRD, council vice president; Carol Krol, DC, RCRD, council secretary-treasurer, Dr Paul A. Jaskoviak, Parker College of Chiropractic; Ronald H. Grant, DC, FICC, Logan College of Chiropractic; Ronald D. Williams, DC, National College of Chiropractic; Don Eggebrecht, DC, DACBO, Northwestern College of Chiropractic; J. Clay McDonald, DC, DACRB, Palmer College of Chiropractic; Peter Milanovich, DC, PT, private practitioner and Robert A. Goldman, MS, PT, private practitioner.
Table 3 - Physical Medicine and Rehabilitation
Modalities – Any physical agent applied to produce therapeutic changes to biologic tissue; includes but is not limited to Thermal, Acoustic, Light, Mechanical or Electric energy.
97139 – Unlisled therapeutic procedure (specify)
97150 – Therapeutic prooodure(s), group (2 or more Individuals)
97250 – Myofascial release/soft tissue mobilization, one or more areas regions
97265 – Joint mobilization,one or more areas (peripheral or spinal)
97500 - Orthotics training (dynamic-bracing, splinting), upper and lower extremities; initial 30 minutes, each visit
97501 – Each additional 15 minutes
97520 – Prosthetic training; initial 30 minutes, each visit
97521 – Each additional 15 minutes
97530 - Therapeutic activities, direct (one-on-one) patient: contact by provider (use of dynamic activities to improve functional performance), each 15 minutes
97535 – Self-care home management training (e.g., activities of daily living (ADL) and compensatory training meal preparation, safety procedures and instructions on use of adaptive equipment), direct contact by the provider each 15 minutes.
97537 – Community/work re-integration training (e.g. shopping, transportation, money management, vocational activities and/or work enviroment/modification analysis, work task analysis), direct one-on-one contact by the provider, each 15 minutes.
97542 – Wheelchair management/propulsion training, each 15 minutes.
97545 – Work harding/comditioning; initial 2 hours.
97546 – Each additional hour
Supervised – The application of a modality that does not require direct (one-on-one) patient contact by the provider.
97010 – Application of a modality to one or more areas; hot or cold packs
97012 – Traction, mechanical
97014 – Electrical stimulation (unattended)
97016 – Vasopneumatic devices
97018 – Paraffin bath
97020 – Microwave
97022 – Whirlpool
97024 – Diathermy
97026 – Infrared
97028 – Ultraviolet
Constant Attendance – The application of a modality that requires direct (one-on-one) patient contact by the provider.
97032 – Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes
97033 – Iontophoresis, each 15 minutes
97034 – Contrast baths, each 15 minutes
97035 – Ultrasound, each 15 minutes
97036 – Hubbard tank each 15 minutes
97039 – Unlisted modality (specify type and time if constant attendance)
Therapeutic Procedures – A manner of effecting change through the application of clinical skills and/or services that attempt to improve function. Physician or therapist is required to have direct (one-on-one) patient contact.
97110 – Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112 – Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception
97113 – Aquatic therapy with therapeutic exercises
97116 – Gait training (includes stair-climbing)
97122 – Traction, manual
97124 – Massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
Test and Measurements
97703 – Checkout for orthotic/prosthetic use, established patent, each 15 minutes
97750 – Physical performance test or measurement (e.g., musculoskeletal functional capacity), with written report, each 15 minutes
Other Procedures
97770 – Development of cognitive skills to improve attention, memory, problem solving; includes compensatory training and/or sensory integrative activities, direct (one-on-one) patient contact by the provider, each 15 minutes
97799 – Unlisted physical medicine/rehabilitation service or procedure
Biofeedback
90900 – Biofeedback training; by electromyograrn application (e.g., in tension headache, muscle spasm)
90915 – Other training (dynamic-bracing, splinting), upper and lower extremities; initial 30 minutes, each visit.
The utilization of these physiotherapy guidelines may be helpful In clinical applications.
Conference participants reviewed current Agency for Health Care Policy and Research (AHCPR) positions relative to physical modalities, transcutaneous electrical nerve stimulation, shoe insoles/lifts, lumbar corsets/belts, traction and biofeedback.' Prior to the conference, attendees concurring with the AHCPR positions relative to acute low back pain felt that there was the necessity of a complete review of the same journal studies and articles. These are being compiled to be made available to each of the chiropractic colleges. Howevm it was felt that conference participants could develop a consensus as to the stage and time frame utilization of the most common adjunctive therapies, if chosen to be utilized by a clinician.
Stages and Time
Course of Episode
To use physiological therapeutics on a rational basis, the practitioner must have knowledge of the actions and an understanding of their predictable effects on the tissues and pathophysiologic processes involved. Adjunctive therapy applications can then be provided according to the stages of episode, as published by J. Frymoyer (Table 1).
Conference participants developed an initial agreement on the treatment stages of the commonly utilized modalities and procedures. The treatment time range (low-high) of each modality-procedure was agreed upon based on effective clinical application. This was followed by a review by each CCE chiropractic college physiotherapy departmentt with a recommendation back to the council. Each CCE college had the opportunity for a final review and comment on the treatment stage and treatment time given to each modality-procedure. The final consensus is outlined in Table 1.
CPT Code Applications
The practicing clinician is faced with making daily treatment decisions. The practical difficulty is in assigning the correct CPT code to the treatment rendered." The current 1996 CPT codes are listed in Table 3. The Physiotherapy-Rehab Guidelines (Table 2), as assigned a CPT code are provided in Table 4. Under certain circumstances, a service or procedure is partially reduced at the clinician's discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier, -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.
Table 4 - CPT Codes
Modality-Procedure CPT Code
Cryotherapy 97010
Ice massage 97010,97124
Heat-superficial
Infrared heat light 97035
Hot packs 97010
Paraffin 97018
Hydrotherapy 97024
Heat--deep
Ultrasound 97035
Continuous 97035
Pulsed ultrasound 97035
Diathermy 97024
Microwave Diathermy 97020
shortwave diathermy 97024
EMS (unattended) (attended)
Subsensory stimulation 97014 97032
TENS 97014 97032
Muscle stimulator 97014 97032
Muscle stimulation 97014 97032
Trigger point 97014 97032
Mechanical Vibration 97124 97039
Traction (in-office) (mechanical) (manual)
Continuous 97012 97122
Intermittent 97012 97122
Intersegmental 97012 97122
Flexion-distraction 97122
Extension compression 97012
Ambulatory 97012, 97110, 97530, 97112
Massage 97124
Myofascial Release 97250
Trigger Point Therapy 97139
Exercise (in-office)
Passive 97110
Active 97110, 97530
Work Hardening 97545
Activities of Daily Living 97535
Biofeedback (in-office)
Muscle re-education 90900, 90915
Relaxation/pain reduction 90900, 90915
Bracing 99070
Conclusion
The utilization of these physiotherapy guidelines may be helpful in clinical applications. It is not the intent of these guidelines to recommend the use of any specific modality-procedure. Each clinician must depend upon his or her own knowledge of chiropractic and expertise in the use or modification of these materials and information. Generally, passive care is time limited, progressing to active care and patient functional recovery.
Further research appears necessary in order to obtain a consensus of the clinical guidelines of the application of specific physiotherapy-rehabilitative procedures, concerning the restoration of function and prevention of disability following disease, injury or loss of a body part. The question to be debated in this regard is whether only randomized controlled clinical trials (RCM should be used to evaluate the efficacy of clinical regimes. It is certainly the most persuasive design for considering treatment efficacy. However, it would be a grave error to disregard all studies that did not incorporate this design.
The effects of insulin on diabetic hyperglycernia, of penicillin on pneumococcal pneumonia or of vitamin B12 on pernicious anemia have been accepted without demands for randomized trials. Although dramatic
treatment effects such as these are not the rule, they clearly show the fallacy of assuming that only RCTs can demonstrate treatment feasibility.
References
1. ACA Council on Physiological Therapeutics.
"Physiotherapy Guidelines for the Profession"
ACA Journal June 1975, 9, S-66
2 Jaskoviak, PA and RC Schafer,
"Applied Physiotherapy"
Arlington, Va.: The American Chiropractic Association, 1993,1-3.
3. Thomas, CL, ed.
"Taber's Cyclopedic Medical Dictionary",
14th edition. Philadelphia: EA. Davis, 1981; 1098
4. Peterson, D and G Wiese.
"Chiropractic: An Illustrated History. ",
St. Louis: Mosby Year Book, Inc. 1985.
5. Bigos S, Bower O, Braen G, et al.
Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14.
Rockville, MD: Agency for Health Care Policy and Research,
Public Health Service, U.S. Department of Health and Human Services; 1994
6. Frymoyer, J.
"Back Pain and Sciatica."
New England Journal of Medicine. 318: 291-300
7. American Medical Association.
Physicians' Current Procedural Technology- CPT 1996.
Chicago: American Medical Association, 1995
Guidelines Authors
Kim D. Christensen, DC, DACRB, CCSP, President, ACA Council on Chiropractic Physiological Therapeutics & Rehabilitation
Paul A. Jaskoviak, DC, DACAN,CCSP, FICC, Postgraduate Director, Parker College of Chiropractic
Ronald H. Grant, DC, FICC, Associate Professor, Chiropractic Science Department, Logan College of Chiropractic
J. Clay McDonald, BS, DC, DACRB, Director of Ancillary Procedures, Palmer College of Chiropractic
Ronald D. Williams, DC, Chairman, Department of Chiropractic Practice, National College of Chiropractic
Don Eggebrecht, DC, DABCO, Northwestern College of Chiropractic Paul D. Hooper, DC, Chairman, Department of Principles & Practice, Los Angeles College of Chiropractic
Edward B. Feinberg, DC, DACBSP, Professor, Department of Practice, Palmer College of Chiropractic West
Rickard J. Thomas, BA, DC, Director of Clinical Sciences, Cleveland Chiropractic College, Kansas City
Glenn E. Johnson, DC, Department of Chiropractic Sciences, Cleveland Chiropractic College, Los Angeles
John H. Merrick, MA, PT, DC, Postgraduate Chairperson, Chiropractic Rehabilitation, New York Chiropractic College
Joel P. Agresta, PT, DC, Clinical Science Department, Western States Chiropractic College
Elham Nia, DC, Physiological Therapeutics Department, Royal Melbourne Institute of Technology
Phil C. Lening, DC, Associate Professor, Clinical Sciences Department, Texas Chiropractic College
Robert A. Goldman, MS, PT private practice Vancouver, Wash.
Peter Milanovich, PT, DC private practice Portland, Ore.
Paul Hetrick, DC, RCRD, Vice President, ACA Council on Chiropractic Physiological Therapeutics & Rehabilitation
Carol Krol, DC, RCRD, Secretary/Treasurer ACA Council on Chiropractic Physiological Therapeutics & Rehabilitation
Return to GUIDELINES
Return to REHABILITATION DIPLOMATE
| Home Page | Visit Our Sponsors | Become a Sponsor |
Please read our DISCLAIMER |