This special section features short articles that provide an in-depth look at some of the products and technologies available for PTs. These descriptions were submitted by the respective manufacturers/suppliers upon request of Physical Therapy Products. Visit www.PTProductsOnline.com for more information on the companies and/or products highlighted in this section.

· Cascade Dafo
· Rehab Documentation Co
· OPTP
· The Saunders Group
· IOMED Inc
· Anodyne Therapy
· Clinicient
· Pro-Tec Athletics
· The Financial Effects of Coding Correctly
· Thought Technology

Cascade Dafo

Positioning Control and Rehab Support for a Nonambulatory Patient

H.K. is a 16-year-old female with hydrocephalus and muscle contractures. She is currently nonambulatory. H.K.'s PT reported that her primary goal for the braces is to provide positioning control. The PT would also like to begin a program to include supported standing.

Initial observation revealed narrow feet with delicate-looking skin and coloring that hinted at possible circulation problems. Her feet were severely pronated, and ankle alignment was plantarflexed. The navicular, first metatarsal phalangeal joint, and base of fifth metatarsal were very prominent points of surface anatomy. The parents' concerns about skin breakdown verified the need to approach brace selection with extra-special attention to comfort and skin health.

A team consisting of the PT, the orthotist, the orthotic assistant, and the patient's mother discussed the merits and drawbacks of several styles and settled on the DAFO 3.5 Softy design. Its separate inner liner protects the skin as the foot is slipped into the plastic outer shell. This also makes donning a bit easier by creating a two-stage routine of foot position followed by dorsiflexion (DF) correction. The posterior strut of the 3.5 will allow enough support without going beyond what is required for occasional supported standing. The proximal section is more open than a fully wrapped AFO and will provide more airflow to her delicate skin.

Upon manipulation, I discovered a range of motion that would allow significant, though not complete, correction to H.K.'s foot and ankle position. A helper was enlisted to hold her knee in a fixed position in the frontal plane. With a firm grip covering a maximum surface area, each foot was gently moved closer to a balanced alignment. One hand wrapped around her heel and the other at her forefoot allowed the proximal and distal sections of the foot to aid each other in correction. With the foot alignment held, her ankle was slowly moved toward DF.

Figure 1	Figure 4
Figure 2	Figure 3
Figure 1. H.K.’s feet on initial observation. Figure 2. Holding H.K.’s foot in our goal for a finished brace position: only a few degrees away from a vertical heel, neutral forefoot and 90-degree dorsiflextion ankle. Figure 3. Repeating the rehearsal positioning of H.K.’s foot while the tape cures. Figure 4. H.K. wearing the braces, feet gently corrected.

After casting with a fairly tight overlapping wrap to be sure every nuance of H.K.'s foot was captured for the technicians at Cascade, the previously rehearsed positioning was repeated. As the tape cured to a more plastic stage, I made sure to further define around her surface anatomy. I removed the cast and checked it for accuracy.

At the fitting appointment, I fine-tuned the toe length and distal medial and lateral trimlines by removing any unnecessary length. If the navicular area does crop up later as a problem, the 3.5 Softy design allows for a particularly good solution. A hole can be cut in the plastic just slightly beyond the apex of the navicular. Cutting this hole will allow the navicular to ease out through the plastic while it continues to remain contained by the soft liner. This adjustment was not necessary at the fitting. In fact, if all goes as well as planned, we will not have the pleasure of seeing H.K. again for quite some time.

Loretta Sheldon, ROA, is an ABC registered orthotic assistant with Cascade P&O in Ferndale, Wash. Sheldon can be reached .

Rehab Documentation Co

One of the primary challenges of managing a physical rehabilitation practice is knowing and keeping track of the ever-changing reimbursement parameters required by your pay sources. In today's market, with diminishing reimbursement rates, it is a necessity for the health of your business to optimize your reimbursement through correct coding.

To assist you with keeping track of the trends of your payors, ReDoc has developed our ReClaim Module. This additional feature of ReDoc offers you the ability to input the conditions for payment of your pay sources based on three basic filters: medical necessity (ICD-9 to CPT Code combinations), NCCI Edits (based on the NCCI Edits and CPT to CPT code combinations), and excluded benefits (based on a specific CPT code and the specified pay source, such as which insurance company pays for Iontophoresis-97033).

When the therapist is setting up the treatment plan for a specific patient or entering charges, an alert is given when one of the established filter conditions is triggered. Included in this alert are instructions for correct coding and communications to the therapist as to how to document that situation to ensure coverage of the provided service. In short, the information from the billing expert is readily available to the therapist at the specific time that he or she is making decisions about the patient's care.

To obtain information about the NCCI Edits and a copy of the 2007 NCCI Updates the following links are provided for your convenience.

For information about NCCI Edits: http://www.cms.hhs.gov/NationalCorrectCodInitEd/

For the 2007 NCCI Updates: (See Downloads on this page)

For more information, contact The Rehabilitation Documentation Co, (888) 401-4400, www.rehabdocumentation.com.

OPTP

Multifunctional UE Ranger

The UE Ranger is a unique motion-assistance device designed to increase range of motion (ROM) and complement the natural movement patterns of the upper extremity (UE). The UE Ranger allows all phases of rehabilitation to be executed in a functional manner while simultaneously safeguarding the healing structures.

The UE Ranger is designed to support the hand of the involved extremity and accommodate the hand in a resting, "no grip" position. Combined with the securing strap, this feature eliminates the gripping requirement and the potential negative influence of superfluous muscle activity elicited at the rotator cuff. Eliminating unnecessary muscle recruitment enables the patient to sense an accurate and appropriate progression of motor activation for a given movement. This helps in healing and muscle re-education. In addition, the effortless articulation at the wrist and base allow for frictionless movement, making the UE Ranger excellent when working with Rotator Cuff Syndrome; Adhesive Capsulitis; postmastectomy patients; sports rehabilitation; and neurological concerns such as PNF patterns, stroke, and balance.

In addition to ROM exercises, the UE Ranger can be used to provide limb support while the therapist performs myofascial release techniques to affected areas of the shoulder. The UE Ranger provides both the necessary support and progressive challenge capabilities to safely restore full UE function. It provides gravity support, comfortable positioning, and full ROM that promotes movement without limb loading. This is especially important in the early stages of healing.

The UE Ranger allows for natural graded progression of motor control by supporting full-body kinematic-chain functional activities, ADLs, or sport-specific exercises. Using the UE Ranger, balance exercises can be dynamically supported, therefore increasing challenge without compromising safety.

Consisting of a molded plastic bilateral hand support and strap, telescoping tube, detachable base, and articulating joints, the UE Ranger is ideal for all hand sizes and arm lengths, while the add-on wall mount allows progression using horizontal load-bearing motions.

For more information, clinical study information, video clips, or a free OPTP catalog, visit www.optp.com or call (800) 367-7393.

Sandy L. Burkart, PhD, PT, is with Functional Rehabilitation Seminars. For more information, contact .

The Saunders Group

Exercise is a cornerstone of effective rehabilitation. While clinicians can teach and supervise exercise regimens in the clinic, they cannot control what patients do after they leave. Simply showing patients which exercises to perform is usually not enough—patients need concise instructions to take home with them. New-generation software, such as The Saunders Group’s PhysioTools Exercise Software, offers advanced, intuitive sorting features so clinicians can quickly and easily create custom exercise handouts. Using PhysioTools, clinicians could also develop and store their own protocols and instructions.

The following example illustrates how PhysioTools software saves time and improves patient compliance. PT Marie Smith uses exercise extensively to help rehabilitate her patients with rotator cuff injuries. Prior to installing PhysioTools, Marie either pulled photocopies of individual exercises from a file cabinet (then stapled them together), or "premade" protocols by copying several commonly used rotator cuff exercises onto a single sheet. Inevitably, the precopied protocol would contain an inappropriate exercise for an individual patient, and Marie would simply cross it off, regretting the unprofessional look of the handout. Over time, photocopies would degrade in quality, and Marie frequently found the copies left behind in the treatment room.

After installing Physiotools, Marie found that it was a simple matter to find her favorite exercises and store them together as a protocol. If she noted that a certain patient needed an extra exercise or two, she could add them to the protocol "on the fly." Because the high-quality printouts contained Marie’s clinic logo and the patient’s name, Marie found that patients tended to "remember" their handouts when leaving the clinic.

Each PhysioTools module contains exercise content written by experts including H. Duane Saunders, Shirley Sahrmann, and Mark Commerford. Additional features include the ability to customize handouts, quick and intuitive exercise finding and sorting, and patient record-keeping. No additional software is required—users simply install and run. The 14,000 exercises are illustrated via line drawing or color photograph. Some include video clips and multiple languages.

The complete PhysioTools library contains more than 45 individual modules and 14,000 exercises. In addition, five professional collections bundle individual modules by area of specialty. These include Physiotherapy, Occupational Therapy, Pediatrics, Sports and Fitness, and Manual Therapy. Networking is also available. A free demo CD is available through The Saunders Group Inc.

For more information, call (800) 779-2040 or visit www.TheSaundersGroup.com.

Top: Hybresis Charging Station Bottom: Hybresis Controller on Patch

IOMED Inc

Hybresis™ System: Innovation in Iontophoresis

The Hybresis System, a new iontophoresis drug delivery system developed by IOMED Inc, Salt Lake City, combines the controlled drug delivery of standard iontophoresis with the convenience and time savings of a patch. The Hybresis System contains a miniaturized rechargeable controller that has typical features of a standard iontophoretic dose controller (Phoresor®), but connects directly to the patch (bottom) that has built-in batteries (6 volts), eliminating all wires. The charging station (top) has four bays for charging the Controllers.

The Hybresis treatment consists of a 3-minute in-clinic Skin Conductivity Enhancement (SCE) treatment that rapidly decreases skin resistance followed by the patient wearing the patch for 1 to 2 hours for a prescribed dose of 40 mA-per minute, 60 mA-per minute, or 80 mA-per minute. The 3-minute SCE treatment reduces costs by increasing patient throughput, increases revenue by increasing billable patient time, and is comfortable for the patient. The in vivo Hybresis study is published in the April 2007 issue of Drug Delivery Technology and Hybresis White Paper.

The versatile Hybresis System also provides standard and patch-only iontophoresis treatments with only one patch to inventory. The standard treatment provides a 40-to-80-mA-per minute dose at 2 mA, 3 mA, or 4 mA. The patch-only treatment allows the patient to leave the clinic after application to receive a 40-to-80-mA-per minute dose over 2 to 4 hours. This four-channel Hybresis System provides three types of treatments—hybresis, standard, and patch-only—thus, it is the Quantum Leap in Iontophoresis.

The major advantage of standard iontophoresis products, which have been on the market for 25 years, is their ability to control drug delivery. Some of the disadvantages are that wires to the dose controller tether the patient and it takes in-clinic time to set up and administer the treatment. The Hybresis System combines the advantages of older types of standard iontophoresis products and newer low-voltage iontophoresis patches while eliminating their respective disadvantages.

For more information, contact IOMED, (800) 621-3347, www.iomed.com.

Anodyne Therapy

Seven Considerations for Selecting a Light Therapy Device

It can be difficult to compare light therapy devices and manufacturers. Consider your clinical practice, agency, or facility and its needs first.

1. What conditions do you treat in your practice? Arthritic knees are often bilateral problems requiring multiple treatment arrays. For trigger-point therapy, one array is adequate. For symptoms of carpal tunnel, up to eight arrays may be needed if there is neck involvement. Treating foot and leg pain will require a minimum of four arrays—and eight are ideal since the area covered helps determine the treatment effect. If you plan to treat TMJ or myofascial pain, you will need arrays that are small enough to place on the face. The device design you select should be flexible enough to allow you to treat all the conditions you intend to treat.
2. What do you want the photo-energy device to do for your practice? Do you want to add new services or enhance the ones you have? Are physicians asking you to provide this service? If so, what types of patients will they be referring to you? Is your practice running at full capacity, or do you want to increase referrals? Will you add therapists if you get increased referrals?
3. Do you do your own marketing?
   Do you have the resources to create your own marketing materials? If not, how will you market this new technology? Do you need marketing support from the manufacturer? Will the manufacturer assist you in educating and marketing to your referring providers?
4. What are the demographics of your area?
   Is the population in your service area predominantly young families, or are you near a big senior community? This may dictate what new services you want to offer with your photo-energy device so that you have a built-in referral base.
5. Do the physicians in your service area tend to be skeptical of new technology, or are they innovative and willing to try new things?
   If the physicians tend to want clinical proof of outcomes and are skeptical of new medical technologies, then having published clinical data to ensure they "buy in" will be critical.
6. Should I consider a laser or a device with LEDs?
   Devices should be evaluated based on the conditions and size of the area you need to treat and the outcomes you want to produce. Lasers and LEDs will penetrate to approximately the same depth if the wavelength, treatment area, and power (milliwatts) emitted are the same, because light fractionates and reflects when it hits tissue. Ask the manufacturer for clinical studies using their device and treatment-time protocols on the conditions you will be treating. Using clinical data from devices that use different wavelengths, power, treatment times, and areas covered will not produce the same results.
7. What are your regulatory requirements?
   Do you need a device that is OSHA compliant and was cleared through the FDA 510(k) process?

For more information and a free light therapy comparison guide, contact us at (800) 521-6664 or .

Clinicient

Clinicient Insight™ is integrated practice-management software designed to meet the specific needs of rehabilitation providers. Clinicient Insight's unique system for patient registration, scheduling, clinical documentation, procedure code aggregation, billing, financial management, and business-analysis tools are designed so everyone in the clinic has access to the information they need to do their jobs more effectively and efficiently.

How It Works

Information associated with the patient's case, such as insurance authorization information, is entered during the registration process. This information is used throughout the patient's treatment to alert and inform clinic staff. For example, a Clinicient Insight user will be alerted when a new physician referral is needed.

This information is also available to the therapist, who uses it to develop the patient's clinical documentation. As the therapist documents services performed in Clinicient Insight, CPT Codes are automatically aggregated based partly upon the services provided and partly on any billing rules that have been established for the patient's payor. When the therapist signs off on the documentation for the visit, the system audits the aggregated procedures for compliance and will prompt the therapist to apply any appropriate billing rules.

In addition, Clinicient Insight will automatically alert the therapist in a number of ways. For example, if a patient is approaching the Medicare cap, the therapist will be provided with that information and can make a clinical decision at that point whether or not applying a KX modifier to continue treatment past the cap limitations is appropriate.

The clinical documentation tool in Clinicient Insight is completely configurable and flexible. The system is preloaded with a comprehensive, multidisciplinary set of documentation templates. Clinicient Insight users can modify those templates to meet their own specific needs and can also create templates from scratch.

All of the information gathered by using Clinicient Insight is used by a sophisticated data-analysis feature to provide clinical and financial outcomes. The data-analysis feature allows management to "drill down" into any number of predefined reports that reveal specific metrics that drive their business.

With Clinicient Insight software, therapists are able to customize their clinical documentation environment to ensure compliance and meet the needs of the referring doctors.

Pro-Tec Athletics

Ice Massage: How Ice Works

Appropriate application of ice to areas of inflammation will cause your superficial blood vessels to contract. This contraction helps temporarily reduce the blood in the area, like squeezing out a sponge. The blood is then forced to move toward the heart. As the area warms up, the blood vessels expand, allowing for fresh new blood to come in and continue the healing process.

Another benefit of cold therapy is the reduction of pain. Decreasing blood flow to the nerves around an injured site causes temporary numbness. In addition, since sensory nerve signals are sent to the central nervous system faster than pain signals, the cold sensation is felt instead of the pain sensation. This is important in interrupting a pain cycle, allowing the surrounding muscles to relax rather than "guard" the area in pain.

The most common method of cold therapy is the use of an ice pack, although in recent research, the use of direct ice—more commonly known as ice massage—has been shown to be more effective in treating inflammation. Ice massage is the use of ice directly on the skin in a massaging motion with light to moderate pressure.

Benefits of ice massage include:

• Quick, deep tissue penetration, effectively reducing inflammation and pain;
• Decreases the length of the inflammatory process, leading to faster recovery;
• Decreases treatment time (3 to 10 minutes), compared to other cold applications (15 to 20 minutes); and
• Safe and easy to perform.

When to Use Ice Massage?

• Immediately following acute musculoskeletal injuries where swelling, inflammation, and/or muscle spasms are occurring;
• Immediately following activities during all stages of healing; and
• Multiple times throughout the day during all stages of healing, as often as every hour.

Ice Massage Technique:

• Use an ice cup or the Pro-Tec Ice-Up portable ice massager directly on the area you wish to treat.
• Apply the ice directly to the skin over the affected area, while keeping it moving with mild to moderate pressure.
• The treated area will experience four primary sensations: cold, burning, aching, and numbness.
• The length of time it takes to go through these stages will vary depending upon the stage and severity of the injury. Continue for approximately 3 to 10 minutes through the above stages of sensation.
• Stop when numb or slightly sooner to avoid freezing the skin, and allow the tissue ample time to warm up before stretching or performing other activities.
• Note: Ice massage may be contraindicated for individuals with neurological and circulation conditions that limit sensation and blood flow.

Scott Jurek, MA, PT, is a seven-time Western States 100 Mile Champion. For more information, contact .

The Financial Effects of Coding Correctly

The BMS Reimbursement Evaluation is a proprietary tool that reviews levels of payment and treatment with the end result revealing specific areas that require focus to increase revenue. The typical percentage of revenue increase found in the Reimbursement Evaluation, expressed as a percentage of current revenue per visit, ranges from 10% to 24% for 90% of practice owners.

Methodology. The reimbursement evaluation has been used by and refined through the analysis of hundreds of PT-owned practices across the country, with the resulting analysis affirmed by practice owners. We reviewed data over a 6-month time frame that included: gross charges, collections, adjustments, month-end accounts receivable, visit, new patients, an aging summary, and payor class breakdowns. The resulting data was refined to a treatment profile and revenue (payment) per visit figure for the practice by major payor class with average for the practices. We were able to compare timed and untimed code units per visit as a determinant of payment per visit. Finally, we compare benchmarks for these practices against the norm for a private-practice PT practice in that geographic region. The data resulting from the Reimbursement Evaluation was compared to benchmark data for a given state, region, or locality, and adjusted for participation in network arrangements.

Analysis. What we found in these two analyses was that practices averaged 2.1 to 2.4 timed units per visit with the patients being in the treatment area of the practice for an average of 74 minutes. The range of reimbursement per visit was $76 to $84. The benchmark figure of units per visit was 2.8 to 3.4, which would equate to average revenue per visit of $94 to $106 per visit—a difference of $18 to $22 per visit. This treatment provided in the practices did not accurately represent the number of services billed for in the practice. The financial impact of learning to code for physical therapy services has a significant impact on the financial health of the physical therapy practice by adding additional revenue directly to the bottom line of the practice.

Solution. We provided our clients with secure, Web-based outsource billing solutions, and accounts receivable management services. They freely access online analysis and management tools to identify critical issues under their control to increase their revenue per visit.

Our regularly scheduled training programs are targeted on reviewing recent regulatory and coding changes affecting their practices.

For more information, contact BMS Reimbursement Management, (877) 774-6625, www.bmsreimbursement.com.

Figure 1.

Thought Technology

Stay Healthy at the Computer: Lessons Learned from Research

Do the following experiential practice:

Sit on the edge of your chair and hold your mouse and then begin to draw with your mouse, the letters and numbers of your street address; however, draw the letters backward by beginning with the last letter of the street address. Draw each letter about 1 1/4 inch in height, and then click the left button after having drawn the letter. Continue to draw the next letter. Draw as quickly as possible without making any mistakes. Start now, and continue for the next 30 seconds

Stop and observe how you feel.

Did you notice that you held your breath, tightened your shoulders, forgot to blink, and even tightened your trunk as you drew the letters with your mouse? Imagine what would happen if you worked like this hour after hour?

The majority of employees who work on computers experience discomfort ranging from neck, shoulder, back, and arm pain to eye irritation and exhaustion. A major cause is the holding of chronic and unnecessary muscle tension—tension of which the employee is usually unaware and leads to illness. Research at San Francisco State University have demonstrated with biofeedback that 95% of employees automatically raised their shoulders as well as maintained low-level tension in their forearms while keyboarding and mousing, as well as increased their breathing rates and decreased eye blinking rates. Almost all employees studied thought that their muscles were relaxed when they were sitting correctly at the computer, even though they were tense, as is shown in Figure 1.

Figure 1 is a representative recording of a person working at the computer. Note how 1) forearm and shoulder (deltoid/trapezius) muscle tension increased as the person rests her hands on the keyboard without typing; 2) respiration rate increased during typing and mousing; 3) shoulder muscle tension increased during typing and mousing; and 4) there were no rest periods in the shoulder muscles as long as the fingers are either resting, typing, or mousing.

Begin a self-training program using biofeedback as described in the book by Erik Peper & Katherine H. Gibne. Muscle Biofeedback at the Computer: A Manual to Prevent Repetitive Strain Injury (RSI) by Taking the Guesswork Out of Assessment, Monitoring and Training (The Biofeedback Foundation of Europe, 2006). It is available at www.bfe.org.

To learn more about biofeedback equipment, contact Thought Technology Ltd at www.thoughttechnology.com.

Erik Peper, PhD, is a professor and codirector of the Institute for Holistic Healing Studies in the Department of Health Education at San Francisco State University. He can be reached at .