Alternative concept to improving Range of Motion

How often have we considered that our patient may be limited in their range of motion because they lack stability?

When I was in PT many years ago, I was taught that a person needs to have stability in order to have mobility. This is a well established rehabilitation concept and an often utilized principle with regard to positioning in the neurological patient population.

Stability within our system comes from our core muscles. They are the deep 1 joint muscles that are found in every joint and they must fire in order to allow our moving muscles to work. A good example of the this is the relationship of the rotator cuff  and shoulder flexion. If the rotator cuff is torn, the shoulder joint cannot flex.

If I had been given $100 every time that I gained range of motion with a patient only to find that it was lost on the next visit, I would be very wealthy.

The reason for this can be 2 fold:

• I didn't addressed or assessed the stability component of the joint that I was working on.  
• The patient became inflamed between visits and there was core muscle shut down. Remember for every cubic centimeter a muscle shuts down by 1 %. 

If you find yourself having difficulty gaining or maintaining range in your patient consider addressing the stability of that joint.

The Barrier to Good Posture

"STAND UP STRAIGHT"! 

If I had a dollar every time I heard that phase in a Rehab facility, I would be very wealthy. 

Don't you think our patients would like to have good posture if they could?

So why don't they?  

We are a manifestation of our compensations, meaning that when our body is not in alignment it will compensate to achieve function. 

I also believe that people become "Disabled" when their bodies run out of compensations. 

There are 2 main reflexes that dictate postural alignment in the human body. The body will contort itself by any means possible to achieve the following. 

1. Keeping the eyes on the horizon to facilitate the righting reflex and optimize vestibular function. A prime example of this is compensations due to a scoloitic curve. 

2. Weight bearing of the body over the hallux and medial foot. Examples of compensations include: rotation of the femur or tibia, medial shift of the talus, flat feet, genu recurvatum, genu valgum, anterior innominate rotation, and knee bending in standing. 

Diane Lee uses the term driver to describe the reason that there is a postural abnormality, the driving force behind the postural abnormality.

I feel the best way to determine is to place the bony structure in neutral and do the following: 

1. Observe compensations that occur as a result of this change. 
2. Ask our patients where they feel a resistance to allowing for movement to occur within the system. 
3. Feel through our tactile sense where there is a restriction to movement. 

I term this type of evaluation Diagnostic Static Evaluation. 

The ultimate way to achieve carryover and maximum functioning in your patient is to give your patient the best possible alignment in their system. 

The key to achieving this is to unlock the driver and treat the compensations. 

If you don't the patient will never physically be able to "STAND UP STRAIGHT"!

Tips on how to easily incorporate G-coding into your practice

Here is a video that I put together providing you will tools on how to streamline your documentation to easily incorporate G-coding into practice.

10 Important Facts about Medicare G Codes

Check out this video, its part of a class designed to decipher medicare's new G Code Billing system.

RAC's are a smack in the head for Therapists and Seniors

Unfortunately it was no joke that on April Fool's Day the Manual Medical Review went into process.

This means that there will be pre-payment review (therapists will not be paid for services until after the patient has been seen) for patients who have exceeded the combined $3700 allowed per year for PT and Speech therapy combined in the following states: Florida  California, Michigan, Texas, New York, Illinois, Louisiana, North Carolina, Pennsylvania, Ohio and Missouri. 

For those who practice in states that are not affected by the pre-payment review, Medicare can take your money back in a post-payment audit. 

It is likely that pre-payment review will become a national policy in the near future. 

I watched an informative webinar on this topic that can be found at http://www.clinicient.com/4307-2/ It goes into what is happening and how to document best way possible to defend your services to an auditor.

One of the comments made by the instructor during this presentation that really stuck with me was "CMS (Center for Medicare and Medicaid Services) has designed a system to limit therapy services to Medicare recipients."

They have managed to do this in the following ways:

1. Monetary rewards for auditors. Auditors get paid on a percentage of the money that is recovered, so they are biased.

2. Making the process of review painstaking and lengthy. Reviewers claim it is 10 days, but in reality by the time delivery of documentation and approval and or denial is received (approvals and denials are sent by mail)  it is double that time.

3. Documentation of additional codes: Developing difficult systems like G-codes, PQRS codes, KX modifiers etc... that easily allow for screw ups on a claim and cause a denial to occur. To ensure compliance check out these courses on G-codes found at http://www.sigproed.com/online_courses.html

4. Forcing the Therapist into a difficult moral and ethical circumstance. The therapist now has to decide if they can monetarily afford to provide services to a patient, knowing that they will likely be denied or have to waste time and energy to fight for their money.

I wonder if congressman would have the same rules for Medicare if that was the health insurance that they had to rely on?

Simplifying Medicare G-Codes

Everyone in the therapy community has been buzzing about this topic.  It is the latest form of documentation torture mandated by Medicare.

If you bill Medicare in any way as a provider or non-participating provider it affects you. It also affects  MD's, DO's, and Chiropractors who bill therapy codes, in ALL settings.

The only way to avoid it is to become a provider of a Medicare HMO. Not, in my opinion a great option.

It is vital to all practices that they understand and comply with this information for the following reasons:

• You will not get paid for services after July 1, 2013.
• It will be a part of the mandatory audit that affects therapists when services are provided after the therapy cap has been met. 

Trying to learn this system is not easy and resources are few.

The following are 2 videos that I posted on you-tube:

Top Ten Facts about Medicare G-code Billing and Documentation:

http://www.youtube.com/watch?v=N1CD1fijeHo

and

How to Streamline your Practice while remaining compliant with Medicare G-code Requirements:

http://www.youtube.com/watch?v=gYpv-3z_0pk

The videos are excepts from 2 new online classes:

1. Keeping it Simple: Documenting and Billing to comply with Medicare G-codes

2. Strategies to Streamline your Practice while being compliant with Medicare G-codes.

These courses are are available with a variable fee to allowing you the option to take the class for credit or just for your own information at http://www.sigproed.com/online_courses.html 

The Rules for Rehab

I will never forget my Professor's words of wisdom that were taught to me over 15 years ago.

I use them on every patient that I see and go back to them when a patient is not responding to my treatment.

Thanks Roz

They are:

1. Alignment Dictates Function: If the alignment is off the structure will not work. From the tube like structures in viscera to the bones in a joint, if they are even a millimeter off they will not function optimally.
In muscles this is substantiated by the principle of the Length Tension Ratio which states that a muscle will contract with greatest vigor when it is at a particular length.

2. You need to have Stability in order to Have Mobility: This comes into play with our core muscles. If our core muscles are not firing there is no fix point from which are muscles can move.  It also explains why joint inflammation is such a problem. For every cubic centimeter of inflammation,  a muscle shuts down by 1 percent. The muscles that are closest to the joints are our core muscles. Therefore, people who are inflamed are unstable and will lack flexibility. This rule directly contributed to my developing the ARMS release technique as well as the Position of Manual Stability.

3.  Release, Re-position, and Re-Educate or  just Re-position and Re-educate: If there is a non-structure dysfunction, meaning that if a limitation in motion is not being caused by an anatomical structure, then you would just put the body part where you want it to be (re-position) and re-educate. If however, a structural dysfunction is occurring, meaning that motion is being blocked or limited by an anatomical structure, you need to release it first, then tell the body where it needs to be (re-position) and re-educate.

If you are not having great success with your patients you may want to refer back to "The Rules".