REHABILITATION GUIDELINES
 
   

Physiotherapy and Rehabilitation Guidelines
for the Chiropractic Profession

This section was compiled by Frank M. Painter, D.C.
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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 Please note that some of the CPT codes mentioned may be out of date now. No attempt has been made to re-write 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

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
* Chronic recurrent episodes are treated as acute.


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 et al. "Acute Low Back Problems in adults." Clinical Practice Guideline No. 14. AHCPR Publication no. 95-0642. Rockville, Md.: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 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


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