APTA position on Direct Access for Physical Therapy and Physical Therapists

This is a nice summary for Direct Access to Physical Therapy which in Kentucky is available to all. This comes directly from the American Physical Therapy Association/ 

Direct Access to Physical Therapy Services: Overview

The Problem

While state law generally allows patients to seek evaluation and treatment from a licensed physical therapist without a prescription or referral from a physician, patients are limited in their ability to do so in many states by arbitrary and unnecessary restrictions. These restrictions are typically in the form of time and visit limits, previous diagnosis requirements, limited patient populations, or requiring a referral for certain types of treatment. These restrictions do not recognize the professional training and expertise of the licensed physical therapist nor do they serve the needs of those patients who require physical therapy but whose care is unnecessarily interrupted by these restrictions..

The Solution

Amend current statutes at the state level to remove arbitrary limitations on direct access to physical therapy services.

Rationale

In the age of health care reform, state legislatures continue to seek solutions that will expand access to the health care services the citizens of their state need while also addressing the growth in health care costs. One of the most effective tools for cost control and increased access is easily attainable yet often overlooked and underutilized by the legislatures - that of direct access to the services of nonphysician health care professionals.

Physical therapy is the case in point. Entry into the profession and practice of the profession are stringently regulated by all states, and as highly trained health care professionals, physical therapists have a proven track record of effectively treating millions of patients. Physical therapists are well-qualified, both through formal education and clinical training, to evaluate a patient's condition, assess his or her physical therapy needs and, if appropriate, safely and effectively treat the patient. Physical therapists are also well-qualified to recognize when patients demonstrate conditions, signs and symptoms that should be evaluated by other health care professionals before therapy is instituted. Physical therapists recognize when it is appropriate to refer patients to these other health care professionals for consultation.

Every state, the District of Columbia, and the US Virgin Islands have all recognized the safety and benefits of direct access to physical therapy by removing from their statutes, all or some of the referral requirements or provisions for a physical therapy evaluation and treatment. However, if your state laws continue to include out-dated and unnecessary barriers to direct patient care by physical therapists, please consider the benefits of reform. By amending the physical therapy practice act in your state, you will be providing your constituents with an additional entry point into the traditional medical system, increased choice in the selection of a health care professional, access to less expensive and more timely care, and a simple, yet, extremely effective way to meet the goals of increased access and cost containment.

For additional information on direct access, please contact APTA's state government affairs department at 800/999-2782, ext. 3161.

Chose one that 

Specializes in Dry Needling 

with Advance Training

By making your own decision as to your Physical Therapist then you are taking charge of you, as the most important member of your health care team

You are entitled to choose the most appropriate health care professional to meet your goals. 

You have that Freedom of Choice! 

You have the freedom to choose your own Physical Therapist

How does the dry needling method work: Mechanism of Action
it appears to allow the sarcomere to resume its resting length³ and activate inhibitory dorsal horn interneurons? This implies that DN causes opioid-mediated pain suppression and also blocks any incoming noxious stimulus into the dorsal horn by activating the serotonergic and noradrenergic descending inhibitory systems.⁴

In addition, the levels of two biochemical drop significantly following DN. There is a decrease in local concentrations of substance P and calcitonin gene–related peptide; this development may correlate with the systematic reduction of pain following deep DN.⁵

Furthermore, there are studies currently under way that are using multiple imaging techniques to visualize the cascade of physiologic changes that are possible with the introduction of filiform needles into an MTrPs.

Many of us have areas in our body that feel tense all the time or feel like a hard ball in the muscle.By inserting fine needles into these tight areas, we elicit a “twitch response” or a brief contraction followed by an immediate and long lasting relaxation. 

The needle can treat very deep parts of the muscle, the technique can achieve amazing pain relief that you never thought possible.

Muscular tightness and spasm can lead to compression and irritation of the nerves. When nerves are irritated, they cause a protective spasm of all the muscles to which they are connected. This contributes to the decreased mobility and pain in the area. 

I treat multiple orthopedic and neurological conditions helping patient achieve long-term benefits

I specialize in Dry Needling, an extremely effective technique that uses a very fine acupuncture needle to “deactivate” or “shut down” a trigger points or painful knotted areas in your muscles therapy to improve and maximize a patient’s performance and ability.  

Benefits:
Pain control

1.      Normalizes biochemical electrical dysfunction of motor end plates

2.      Reduces muscle tension Restores/increases motion and function

3.      Desensitizes super-sensitive structures

4.      Promotes healing response in tissue Accelerates return to active rehabilitation

Choosing Your Physical Therapist You are the most important member of your health care team, and you are entitled to choose the most appropriate health care professional to meet your goals. Freedom of Choice You have the freedom to choose your own physical therapist. 

Currently, you may be evaluated by a physical therapist without a physician’s referral in all 50 states and the District of Columbia. In addition, 48 states and the District of Columbia allow some level of treatment by a physical therapist without a physician’s referral (all but Michigan and Oklahoma).* Keep in mind that your insurance policy may require a visit to the primary care physician first or may limit your access to preferred providers only.

Your physician may refer you for physical therapy that is to be provided in the physician’s office, or to a facility in which the physician has a financial interest. If this is your situation, be aware that you have the right to choose your own physical therapist and that you are not obligated to receive physical therapy in any specific facility.

Always insist that your physical therapy be provided by a licensed physical therapist.

How to Choose a Physical Therapist Make sure that you receive physical therapy from a licensed physical therapist. Physical therapists are professional health care providers who are licensed by the state in which they practice. 

If you are receiving physical therapy from a physical therapist assistant, be sure that he or she is supervised by a licensed physical therapist. Ask the physical therapist’s clinic if it participates with your insurance company.

Receiving care from a participating physical therapist should minimize your financial responsibility. There may be good reasons, however, to see a physical therapist who does not participate with your insurance plan.

If you need a physical therapist who has special skills related to your particular condition or if the location or other aspects of the care or the facility meet your needs ,this may be a good choice for you.

Some policies require copayments for services, and the amount of the copayment will depend on whether the physical therapist is part of the insurer’s provider network. You also will have to meet your deductible.

Your physical therapist’s clinic should be able to help you calculate an estimate of your financial responsibilities.

Your first visit should include an evaluation by the physical therapist. Your physical therapist will perform an examination to identify current and potential problems. Based on the results of the examination, and considering your specific goals, your physical therapist will design a plan of care to include specific interventions and will propose a timetable to achieve these goals and optimize your movement and function.

Your physical therapist will likely provide you with instructions to perform exercises at home to facilitate your recovery. You should feel comfortable asking your physical therapist any questions regarding your course of care, including specifics regarding interventions and expectations.

Find a physical therapist in your area at www.moveforwardpt.com

Acknowledgment: Shannon L. Hoffman, PT, DPT

Medicare and Direct Access to Physical Therapy

As promised here is some more information on Direct Access and Medicare ;

Direct Access and Medicare

Medicare beneficiaries are able to go directly to physical therapists (PT) without a referral or visit to a physician. This policy became effective in 2005 through revisions to the Medicare Benefit Policy Manual (Publication 100-02).

Medicare beneficiaries are able to go directly to physical therapists (PT) without a referral or visit to a physician. This policy became effective in 2005 through revisions to the Medicare Benefit Policy Manual (Publication 100-02). The 2005 revisions eliminated the physician visit requirement. However, a patient must be "under the care of a physician," which is indicated by the physician certification of the plan of care. Learn more from a summary of the 2005 revisions..
 

The following information is offered to help physical therapists provide access to PT services to patients and remain in compliance with laws and regulations. For more detailed information on CMS requirements, review section 220.1.1-3 of the Medicare Benefits Policy Manual (.pdf) and national and local coverage determinations.

What the Rules Say

·         PTs must comply with the laws in their state related to the need for a referral for physical therapy. Review your state practice act.

·         The plan of care developed by the PT must be certified by a physician or nonphysician practitioner (NPP) within 30 days of the initial therapy visit.

·         The plan of care must include, at a minimum, (1) diagnoses; (2) long-term treatment goals; and (3) type, amount, and duration of therapy services.

·         Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Stamped signatures are not acceptable. If the order to certify is verbal, it must be followed within 14 days by a signature.

·         Medicare does not require that the patient visit the physician/NPP. However, a physician/NPP may require the visit.

·         Medicare does not require a physician order for PT services.

·         Recertification of the plan of care is required if changes in a patient's condition requires revision of long-term goals or within 90 calendar days from the date of the initial treatment, whichever is first.

What This Means for PTs

To be paid by Medicare for their services, PT practices should have procedures in place to ensure that the plan of care is certified. Medicare does not require certification of the plan of care before treatment is initiated. However, if the PT does not have a relationship with the physician or is not confident that the physician will sign the plan of care, it may be prudent for the PT to contact the physician for verbal authorization before initiating treatment. If state law is more restrictive that Medicare regulations, physical therapists must comply with state law.

Filing Medicare Claims Under Direct Access

Medicare regulations specify how to report information on the certifying physician/NPP on claims for outpatient therapy services:

·         Effective October 1, 2012, providers must report the name and NPI number of the certifying physician/NPP on the claim for therapy services.

·         For claims processing purposes, the certifying physician/NPP is considered a referring provider. The term “referring provider” is used by Medicare in this case simply because this is the term that is currently on the claim form.

·         The use of the term “referring provider” does not change existing regulations stating that Medicare does not require a patient visit with the physician/NPP.

DIRECT ACCESS FOR PHYSICAL THERAPY -- YES YOU ARE IN CONTROL IN WORKING WITH YOUR PHYSICAL THERAPIST

In the State of Kentucky, each individual is allowed direct access to Physical Therapy.  What this means is that you are not only allowed to choose who you want to go to for your physical therapy, but when.  Of course it is a given that early intervention is important in gaining a quick and positive outcome.  There are some caveats for certain insurances like Medicare and Medicaid and I will post that later. However, even with these you are allowed direct access.

Below is a short summary of what Direct Access actually means

"What is Direct Access to Physical Therapy

Question: What is Direct Access to Physical Therapy?

In the past my doctor prescribed physical therapy for me. Now she says that I can have direct access to physical therapy. What is direct access?

Answer:

Direct access refers to the ability of patients to be evaluated and treated by a physical therapist without being referred by a doctor or other healthcare practitioner. If you feel you have a problem that may benefit from the skilled services of a physical therapist, you may be able to refer yourself to physical therapy for treatment. Sometimes direct access is called self-referral.

In the United States, provisions for physical therapy services are governed by each individual state through a "state-practice" act. The practice act is legislation that outlines how physical therapy services will be delivered. Historically, each state's practice act provided that physical therapy services would be provided only if ordered by a licensed physician or other licensed healthcare practitioner. Each state lists different professionals who may refer patients to physical therapy, including podiatrists, dentists and nurse practitioners.

The American Physical Therapy Association (APTA) has lobbied successfully in many states to help change the law to allow patients direct access to physical therapy. By having direct access in each state, physical therapists are recognized as the licensed professionals of choice to initially manage musculoskeletal and movement disorders in patients. You can check to see if your state allows direct access on the APTA's website.

Why Is Direct Access Important?

Healthcare is expensive. It seems that with every passing year, more money is being spent on healthcare, with no objective data that patients are achieving better outcomes. A system that allows the patient to directly seek the services of a physical therapist can help save healthcare dollars by eliminating unnecessary tests or other specialist referrals. Many conditions can be successfully evaluated and treated with no expensive diagnostic testing.

Is Direct Access Safe?

Some opponents of direct access to physical therapy services argue that patients may be put at risk if they visit a physical therapist directly. Physical therapists lack the ability to order certain diagnostic tests or prescribe medication to help manage pain.

To date, there is no objective data indicating that self-referral to physical therapy puts patients at increased risk. Also, there is nothing indicating that self-referred patients consume more healthcare dollars during or after their physical therapy care episode.

Physical therapists are also trained to recognize "red flags" that may signal the need for more invasive medical intervention. In those cases, referral to your physician or healthcare provider is made immediately.

Many states also have safety nets built into the legislation that governs the practice of physical therapy. For instance, some states allow direct access only to therapists who have been practicing for three or more years. Others allow a certain time frame or specific number of physical therapy visits during an episode of care. If the patient requires skilled physical therapy after the time frame or visit threshold is reached, referral to the patient's doctor is mandatory.

If you are suffering from a musculoskeletal condition that causes functional movement limitations, use your best judgment when deciding which healthcare practitioner to see. A visit to your local physical therapist is a safe place to start on the road to recovery. Remember that not all states allow for direct access to physical therapy. You can check the APTA direct access map to see if your state allows direct access. If you are unsure if physical therapy is right for you, a discussion with your doctor may be necessary to help you decide.

_Sources:

_{APTA Direct Access in Practice} http://www.apta.org/directaccess/

_{Pendergast J, Kliethermes SA, Freburger JK, Duffy PA. A comparison of health care use for physician-referred and self-referred episodes of outpatient physical therapy. Health Services Research "}

_{I hope this encourages to take your health care needs into your own control, seeking out your family Physical Therapist} 

I was doing some research on Internet about the swelling I see in certain groups of muscles.  I know it is there, I can see it , palpate it and work on it to relieve it.  Just needed to describe it.  Here is an interesting way to look at the cause.

Treating and Preventing DOMSJohndavid Maes, and Len Kravitz, Ph.D. Articles Reviewed: Connolly, D.A.J., S.P Sayers, and M.P. McHugh. Treatment and prevention of delayed onset muscle soreness. J. Strength Cond. Res. 17(1):197-298. 2003. Szymanski, D.J. Recommendations for the avoidance of delayed-onset muscle soreness. J. Strength Cond. Res. 23(4): 7-13. 2001.  In their review, Connolly et al. (2003) explain that the injury itself is a result of eccentric exercise, causing damage to the muscle cell membrane, which sets off an inflammatory response. This inflammatory response leads to the formation of metabolic waste products, which act as a chemical stimulus to the nerve endings that directly cause a sensation of pain. These metabolic waste products also increase vascular permeability and attract neutrophils (a type of white blood cell) to the site of injury. Once at the site of injury, neutrophils generate free radicals (molecules with unshared electrons), which can further damage the cell membrane. Swelling is also a common occurrence at the site of membrane injury, and can lead to additional sensations of pain. Connolly et al. also note the importance of differentiating DOMS from other injuries such as muscle strains. This difference is important to appreciate because when muscle strain is sustained from vigorous exercise, particularly eccentric exercise, it can severely worsen the injury. In contrast, in a muscle that is experiencing DOMS, continued eccentric exercise is still possible without further muscle damage. When dealing with DOMS it is important to differentiate it from muscle strains, recognizing that continued exercise is still possible with DOMS, but not with muscle strain.

Dry Needling in Kentucky

Sorry it has been so long since I have posted.  We have been in the process of remodeling our clinic and working on getting line up to be able to most effectively work with our patients and clients.  

I did want to mention that Dry Needling is somewhat new to Kentucky.  There are a few PTs in Louisville that are using Dry Needling but as of right now, I don't think there are any in Lexington.  I invite you to search the Internet for information on Dry Needling and possibly decide that it may be something that will help you.  Below is an article from Advance Magazine that discusses Dry Needling. I realize it may be long but it is a good read  

Points of Clarification

Delineating the distinction between acupuncture and dry needling for trigger-point pain

By Dimitrios Kostopoulos, PT, MD, PhD, DSc, ECS, and Konstantine Rizopoulos, PT, DPT, MCMT

Posted on: October 15, 2012

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Vol. 23 • Issue 21 • Page 29 Trigger Point Pain Myofascial trigger-point pain is a prevalent condition facing therapists who treat chronic pain cases. Myofascial trigger-point therapy has become widely used by many healthcare providers for a variety of musculoskeletal problems. Several studies demonstrate a high prevalence of pain due to myofascial trigger points. One researcher suggests that prevalence of pain originating from myofascial trigger points in a general pain practice can reach the level of 85 percent. The recognition of the myofascial pain phenomenon by the medical community as one of the key pain generators has led to the development and expansion of a variety of myofascial therapy interventions. Two instrument-assisted means of treating chronic pain conditions are acupuncture and trigger-point dry needling. Unfortunately, many therapists confuse the terms acupuncture and dry needling, or use the terms interchangeably. However, a clear and definitive distinction exists between the two modalities, and a distinction must be made to avoid confusion. Dry Needling Trigger-point dry needling is one of many treatment methods for myofascial trigger points and it is not proprietary to one specific profession. Trigger-point dry needling is practiced around the world by physicians, physical therapists, acupuncturists, chiropractors, osteopaths, dentists, nurses and many other properly trained healthcare providers who specialize in the treatment of myofascial trigger points. Dry needling is the insertion and repetitive manipulation of a fine, flexible, filamentous needle within a myofascial trigger-point area that produces repetitive local twitch responses and leads to inactivation of the trigger point or a decrease of the trigger-point activity. Preliminary research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation. It's unfortunate that a number of acupuncture practitioners and some of their associations try to equate dry needling with acupuncture, and to make dry needling proprietary to acupuncturists. Some do this by using a modified definition of acupuncture points, which defines an acupuncture point the same as a myofascial trigger point. This creates confusion regarding appropriateness of treatment, which may have negative consequences on consumers deciding on the most appropriate provider for their condition. Belgrade supports that "tender points are acupuncture points and can be often chosen for therapy."1-3 Belgrade uses one of the major criteria used to define a trigger point to also define an acupuncture point. Issues become even more confusing when one considers that trigger-point dry needling,4-6 one of the major treatments for myofascial trigger points, is performed with an acupuncture needle. Acupuncture Acupuncture is a traditional system of Chinese medicine that has been practiced for more than 2000 years.7The Florida State Code defines acupuncture as follows: "Acupuncture" means a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques, that employs acupuncture diagnosis and treatment, as well as adjunctive therapies and diagnostic techniques, for the promotion, maintenance and restoration of health and the prevention of disease. Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi gong, Oriental massage, herbal therapy, dietary guidelines and other adjunctive therapies as defined by board rule. In some manner, the ancient Chinese became aware of certain sensitive skin areas (sensitive points) when a body organ, muscle or function was impaired. They also observed that these sensitive skin areas were the same or similar in all people who suffered from the same impairment. Moreover, the sensitive areas varied consistently according to the organ or muscle function deviating from the norm. It was at this point that some of the relationships among various internal organs or muscles and their functions were observed and established.7-9 Acupuncture was introduced to the West in the 17th century by Jesuit missionaries sent to Peking. In the 1940s, French sinologist and diplomat Soulie de Morant published his voluminous writings on acupuncture.8 Acupuncture was first introduced in the United States in the late 1960s. Since then, Western licensed acupuncturists use acupuncture primarily for the treatment of various conditions such as gastrointestinal problems, gynecological conditions, infertility, musculoskeletal problems, immunological conditions, smoking cessation and many others. Melzack et al found a 71-percent correlation between trigger points and acupuncture points for the treatment of pain.10 Melzack's contention was that trigger points and acupuncture points may have the same neural mechanism. However, new discoveries clearly demonstrate that the trigger-point phenomena originate in the vicinity of dysfunctional endplates,11-12 and this puts an end to the previous claim by Melzack. In a subsequent article, Melzack defines acupuncture and trigger-point dry needling as two distinctively different approaches.13 Recognizing the Distinction Despite some similarities in terms of location between acupuncture points and trigger points, the objective clinician and researcher must recognize the distinct differences. These differences define acupuncture points and trigger points as two completely different clinical entities with possible overlaps.5-14 There are foundational and pathophysiological differences between trigger points and acupuncture points. Classical acupuncture points are identified as precise points along meridians defined by ancient Chinese documents.9 An exception to that are extrameridian and "achi" points. Conversely, myofascial trigger points may be found anywhere within a muscle belly, and there is evidence that their pathophysiological mechanism resides in dysfunctional endplates.12,15 Trigger-point dry needling is a very effective clinical intervention for the treatment of myofascial pain syndrome. While this intervention uses a thin filamentous stainless steel needle, the same as an acupuncture needle, it is distinctly different from acupuncture both in the rationale and its means of application.5-14It is important to understand that these two approaches are very different and require different training for their clinical application. Trigger-point dry needling is not proprietary to one specific profession, but can be practiced by properly trained healthcare providers. Scientific merit requires that we are clear in our distinction between these two separate treatment approaches. References are available at www.advanceweb.com/pt under the Resources tab. Dimitrios Kostopoulos graduated from the New York College of Traditional Chinese Medicine and UHSA School of Medicine. He can be reached at dimi@handsonpt.org. Konstantine Rizopoulos is a graduate of Evidence in Motion's DPT program. He can be reached at kostas@handsonpt.org They are founders of Hands-On Seminars (www.handsonseminars.com) and Hands-On Care Physical Therapy in New York. Therapist, Heal Thyself The concept for a soft-tissue therapy device evolved over the past 25 years treating patients with every condition from carpal tunnel syndrome to low-back pain to plantar fasciitis and more. About seven years ago, I found myself in the middle of battling carpel tunnel syndrome and osteoarthritis in both of my hands, wrists and forearms from the years of practicing soft-tissue therapy without using any professional quality instruments. I searched for a tool that could facilitate my manual therapy techniques and that would ultimately help me get better results for my patients. Finding none, I knew I had to create something myself that would help me continue practicing all of those soft-tissue therapy techniques while simultaneously protecting and rehabilitating myself. The bene?ts of the soft-tissue therapy tool are numerous for both the patient and the therapist. Every millimeter is designed to be in contact with the human body either as a treatment surface, handle/grip or both. The device is very capable at implementing a wide variety of orthopedic and manual soft-tissue therapy treatments, techniques and conditions. These include but are not limited to IT band syndrome, rotator cuff injuries, nerve entrapment, osteoarthritis, psoas release, TMJ, tennis elbow and carpel tunnel syndrome. Clinicians can implement almost any soft-tissue therapy technique regardless of whether it is traditionally applied with a tool or with just the hands. The soft-tissue therapy tool enables clinicians to seamlessly integrate a wide variety of both hand and instrument therapies and techniques with stellar results and ease of use. Self treatment is another designed strength of the soft-tissue therapy tool. A user can easily and effectively treat more than 90 percent of their own body, from the trapezius and teres muscles to the glutes, piriformis, calves, feet, hands, elbows, hips and knees. I was able to treat my carpel tunnel condition successfully with the prototypes I had created of the device. For therapists with limited treatment time, the tool can make a signi?cant impact in as little as a minute or two. It is especially good for isolated pressure points, cross-friction ?ber and myofascial release techniques. This tool is extremely efficient because of the increased leverage and mass that add a tremendous value to the practitioner. They will only need a fraction of the force that they would normally apply to implement the treatment. It is much easier to guide the weight than it is to create the force. The ability to "feel" the tissues is greatly enhanced when utilizing this instrument, much like a needle on a record player as it picks up the vibrations of the music. Treatment with the device is a very stable, comfortable and balanced experience for the therapist. One of the central design elements was to free up the therapist's ?ngers during the treatments so they could be used in conjunction with the instrument to stay in full patient contact. Now, clinicians have twice as much feedback since both the instrument and their ?ngers are actively involved in the treatment. The key thing here is that the instrument by design absorbs all of the treatment force through the palm of the hand and not the ?ngers. Therapists should see the soft-tissue therapy tool do the treatment and let it work for them.   Michael Conchard is an exercise physiologist and the president of Soft Tissue Therapy Tools in Indianapolis.