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Dynamic Chiropractic – January 27, 1997, Vol. 15, Issue 03

Some Chiropractic Mileposts on the Physiotherapy Timeline

By Kim Christensen, DC, DACRB, CCSP, CSCS
The term "physiotherapy" is generally 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.1 With more focus upon our own profession, Jaskoviak and Schafer 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 phrase is also to be considered synonymous with the term "adjunctive therapy."2

 


When did chiropractors first take an interest in adjunctive therapies, and how strong has that attachment been over the years? To answer those questions, we literally need to start "before the beginning":

 


1886-1896: D.D. Palmer's interest in physiological therapeutics possibly began 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.3

 


1914-1918: 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 I.

 


1937: Production of intersegmental traction tables by the Spinalator Company for the chiropractic profession have been documented as early as 1937.3 Logan College of Chiropractic utilized early versions of today's electrotherapy equipment, including the "Polysine Generator" and the "Lightning Electro-Therapy Kit."2

 


1945: 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.3 This included the use of various cycles, stretching mats, parallel bars, proprioception systems and variable resistance exercise devices for all parts of the body (Palmer College of Chiropractic today sponsors a three-year residency program in rehabilitation which is patterned after the popular radiology residency programs throughout the profession).

 


1975: In the June edition of the ACA Journal of Chiropractic for that year, the ACA Council on Physiological Therapeutics published perhaps the first "Physiotherapy Guidelines for the Chiropractic Profession."4

 


1995: In February 1995, the ACA guidelines first presented in 1975 were revisited. 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 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.5 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. However, it was felt that conference participants could develop a consensus on the stage and time usage of the most common adjunctive therapies, if chosen to be utilized by a clinician.

 


Achieving a consensus was important: 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 could then be provided according to the stages of episode.

 


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 department 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, based upon Frymoyer,6 is outlined in Table 1.

 


The utilization of these physiotherapy guidelines (Table 2) has been helpful in clinical applications. However, it was not and is not the intent of these guidelines to recommend the use of any specific modality/procedure. Clinicians must depend upon their 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.

 


1996: The practicing clinician, faced with making daily treatment decisions, also had the difficulty of assigning the correct CPT code to the treatment rendered.7 The 1996 CPT codes appropriate to adjunctive therapies (Table 3) were "matched up" to the Physiotherapy-Rehab Guidelines (Table 4). Under certain circumstances, a service or procedure was partially reduced at the clinician's discretion. Under these circumstances, the service provided could be identified by its usual procedure number and the addition of the modifier, -52, signifying that the service had been reduced. This provided a means of reporting reduced services without disturbing the identification of the basic service.

 


Today: Further research appears necessary 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 (RCT) 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 hyperglycemia, 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 chiropractic profession. ACA Journal of Chiropractic June, 1975; 9:S-66.
  2. Jaskoviak PA and Schafer RC. Applied Physiotherapy. Arlington: The American Chiropractic Association, 1993:1-3.
  3. Thomas CL (ed.). Taber's Cyclopedic Medical Dictionary, 14th edition. Philadelphia: F.A. Davis, 1981:1098.
  4. Peterson D and Wiese G. Chiropractic: An Illustrated History. St. Louis: Mosby Year Book, Inc., 1985.
  5. Bigos S et al. Acute low back problems in adults. Clinical Practice Guideline No. 14. AHCPR Publication no. 95-0642. Rockville: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
  6. Frymoyer JW. Back pain and sciatica. New England Journal of Medicine 1988; 318:291-300.
  7. American Medical Association. Physicians' Current Procedural Terminology -- CPT 96. Chicago: American Medical Association, 1995.

 


Kim Christensen, DC, DACRB, CCSP
Ridgefield, Washington

 



Table 1 -- Treatment Stages and Times of Modality-Procedures
Stages of Episode* Time Course
Acute 0-6 weeks
Stage 1 -- Acute Inflammation 2-3 days
Stage 2 -- Repair-Regeneration day 4-6 weeks
Subacute  
Stage 3 -- Remodeling-Rehab week 7-week 12 Chronic
Stage 4 -- Chronic over 12 weeks

Chronic recurrent episodes are treated as acute.

  • The above stages assume no complications including: obesity; systemic disorders; multiple injuries; increased age; non-compliance 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.6

Table 2 -- Physiotherapy-Rehab Guidelines
Modality-Procedure Treatment Stage Treatment Time Range (Low-High)
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
trigger point 2,3,4 2-5 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 reduct 4 20-30 minutes
Bracing 1,2,3,4 none established
*physician discretion


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.
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
97018paraffin bath
97020microwave
97022whirlpool
97024diathermy
97026infrared
97028ultraviolet
 
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
97033iontophoresis, each 15 minutes
97034contrast baths, each 15 minutes
97035ultrasound, each 15 minutes
97036Hubbard tank, each 15 minutes
97039unlisted 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.
97110therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97112neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception
97113aquatic therapy with therapeutic exercises
97116gait training (includes stair-climbing)
97122traction, manual
97124massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
97139unlisted therapeutic procedure (specify)
97150therapeutic procedure(s), group (2 or more individuals)
97250myofascial release/soft tissue mobilization, one or more regions
97265joint mobilization, one or more areas (peripheral or spinal)
97500orthotics training (dynamic bracing, splinting), upper and/or lower extremities; initial 30 minutes, each visit
97501each additional 15 minutes
97520prosthetic training; initial 30 minutes, each visit
97521each additional 15 minutes
97530therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
97535self-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 one-on-one contact by provider, each 15 minutes
97537community/work re-integration training (e.g., shopping, transportation, money management, vocational activities and/or work environment/modification analysis, work-task analysis), direct one-on-one contact by provider, each 15 minutes
97542wheelchair management/propulsion training, each 15 minutes
97545work hardening/conditioning; initial 2 hours
97546each additional hour Tests and Measurements
97703checkout for orthotic/prosthetic use, established patient, each 15 minutes
97750physical performance test or measurement (e.g., musculoskeletal functional capacity), with written report, each 15 minutes
Other Procedures
97770development 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
97799unlisted physical medicine/rehabilitation service or procedure
Biofeedback
90900 biofeedback training; by electromyogram application (e.g., in tension headache, muscle spasm)
90915 other

 


<
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 diathermy97024 
EMS (unattended) (attended)
subsensory stimulation 9701497032
sensory stimulation TENS9701497032
muscle stimulator 9701497032
muscle stimulation 9701497032
trigger point 9701497032
Mechanical Vibration 9712497039
Traction (in-office)(mechanical)(manual)
continuous 9701297122
intermittent 9701297122
intersegmental9701297122
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
daily activities 97535 
Biofeedback (in-office)  
muscle re-education 90900, 90915  
relaxation/pain red. 90900, 90915  
Bracing 99070 

Click here for previous articles by Kim Christensen, DC, DACRB, CCSP, CSCS.

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