Vol. 17 Issue 18
How one chain of PT clinics utilizes the modality
In an effort to examine how electrical stimulation can be used today in physical therapy clinics, ADVANCE spoke to Chris Tutt, PT, owner and co-founder of ProActive Orthopedic and Sports Physical Therapy, headquartered in Portland, OR, with additional locations in southwestern Washington and southern Oregon. A physical therapist for 13 years, Tutt founded ProActive with two partners about three-and-a-half years ago.
ADVANCE: First of all, as owner and co-founder, do you still maintain an active role in patient treatment?
ADVANCE: What are some of the common conditions patients will present with when they come to ProActive?
Tutt: Being an orthopedic and sports-related [practice], we see everything from ACLs to knee strains, low-back strains, shoulder ailmentsreally the gamut. We also see quite a bit of post-op, laminectomies, some failed laminectomies, as well as diskectomies.
ADVANCE: What is the general age range of the patient population?
Tutt: It probably averages 43 to 45. But we'll see kids as young as 10 to 11, maybe with shoulder injuries from throwing, to an older woman who falls and breaks her hip. So really a wide variety. We see primarily a lot of workers' comp, on-the-job injuries. Probably 65 percent to 75 percent of our business is derived from workers' comp.
ADVANCE: Could you estimate what percentage of the patient population receives electrical stimulation as part of their treatment?
Tutt: I would say probably 50 percent to 70 percent at any given time. It's a great modality we really like it a lot.
ADVANCE: Are they are any conditions for which you would say e-stim is particularly helpful?
Tutt: A lot of the chronic conditions, low-back pain, failed surgical procedures. Many of these people have been on medications for extended periods of time and it's just breaking their bodies down. Give somebody a TENS unit or IF unit and doctors are able to slowly wean them off the medications so they're not medication-dependent.
ADVANCE: Taking the example of patients who come in with low-back pain, what are some specific causes of that pain?
Tutt: SI dysfunction, fisette dysfunctions, lumbar disk herniation. It works really well that you're able to put the pads in the upper extremities where they're feeling the peripheralization of their discomfort and able to reduce their radicular symptoms significantly.
ADVANCE: For a typical patient with lumbar disk herniation, how long would you say the treatment period lasts in terms of weeks coming into the clinic?
Tutt: It depends a lot on the level of the disk herniationwhether there's nerve root impingement or not. But on the average, probably two to three weeks. And people are usually coming in two to three times a week.
ADVANCE: At your facility, what is the length of a typical treatment session?
Tutt: 45 minutes to an hour.
ADVANCE: Again taking the example of the patient with a herniated disk, can you break down the treatment sessionwhere e-stim would come into it, how long the e-stim would take place for and what other types of treatment the patient would receive as part of the 45-minute to an hour session?
Tutt: We focus a lot of on lumbar stabilization, placing the patient's lower back in a position that minimizes any nerve root compression but also causes the least amount of pain. We do a lot of functional activities, emphasizing neutral spine position. That will probably take anywhere from 10 minutes to a half hour. Also use of some soft-tissue mobilization and maybe peripheral nerve mobilization to try and free up any adhesions on the nerve root. That might take 10 to 15 minutes.
Sometimes we'll actually apply the TENS if somebody is a little bit apprehensive about getting in spinal neutral position. Essentially it's masking any discomfort that the patient is feeling and enabling that person to do exercises while the TENS is on. Then we take the TENS off and the patient [generally] doesn't have any appreciable increase in pain. So a lot of it is just removing any apprehension to exercise. If patients are able to exercise without pain, they'll be a lot more likely to adhere to the program.
ADVANCE: In that case, e-stim is more of a supplemental therapy to allow patients to do the exercises you want them to do, as opposed to a primary therapy itself?
Tutt: In some patients, yes. In other patients, we use it strictly as a therapy. But also there are different types of electrical stimulation. You've got TENS for pain modulation. On some occasions, somebody's not able to contract his rectus abdominal muscles. We might use more of a neuromuscular stimulation on those abdominal muscles to get them kicked in. Sometimes erector spinae, if they're having problems kicking those in, to stabilize.
ADVANCE: For the example of patients with lumbar disk herniation where you would use the TENS to help with apprehension and make them more comfortable, how long would the e-stim be kept on?
Tutt: About 15 to 20 minutes.
ADVANCE: And what is an example of a condition where you would use the e-stim specifically for its own therapeutic purposes?
Tutt: That would typically be toward the end of a session, maybe if a patient has some post-exercise muscle sorenessfinish up with electrical stimulation in conjunction with ice. Just to help minimize any of that soreness.
ADVANCE: What is the maximum amount of time in a given treatment session that you would allow e-stim to be provided to a patient?
Tutt: It's so patient-dependent, I would have a hard time putting a maximum on it.
ADVANCE: Is there a minimum amount of time you would say is necessary for e-stim to have some positive impact?
Tutt: Not really, especially when you're talking about TENS. Some people, actually quite a few, we prescribe a home unit. Send them home with that and they're able to leave it on all day long if they'd like in order to perform their daily living activities without medication.
ADVANCE: And there's no danger of any side effects with that kind of sustained exposure over time?
Tutt: As long as people are not over-exerting themselves, there's really not.
ADVANCE: You said anywhere from 50 percent to 70 percent of patients receive e-stim as part of their treatment. Has that been the case for as long as ProActive has been in existence?
Tutt: I would say so.
ADVANCE: And is e-stim something that you have utilized more over the course of your PT career, less, or about the same?
Tutt: It's something I don't think I used as much initially, just because of a lack of continuing education. And the more education you get, you find out this is really a great modality. So I would say I've tended to increase my use of it a little bit over the years. It's an interesting modality in that if you look at outcomes, I don't necessarily think it's going to speed up healing. But I see it really as increasing people's adherence to PT. You're able provide somebody pain relief during the day with the home unit, without medications. And I think that's huge. People are becoming dependent on Oxycontin and a lot of the opiate-derivative drugs. But if you give somebody a TENS unit, the doctor is able to wean that person off these opiate drugs.
ADVANCE: Are those home units something that most patients can get covered through insurance or is it out-of-pocket?
Tutt: Most patients are covered through insurance. The ones that are not covered through insurance, the vendors we deal with a lot of times will be able to make financial hardship arrangements with them.
ADVANCE: Can you provide an estimate of what that would cost if somebody had to pay full price for it?
Tutt: I believe many of the units are about $700, in order to purchase. We don't get too involved with the rentals. But there is a lot of variation within the insurance companies. Some companies will only allow patients to have a certain type of unit, so then they have to find a vendor that dispenses that type.
ADVANCE: Are there any conditions for which you'd be most likely to recommend that patients do e-stim at home in some capacity?
Tutt: I would say irrectractable, chronic low back pain; a lot of the failed surgeries or somebody who's a few days post-surgical. Sometimes doctors will send a patient to us just three or four days [after the procedure] for a TENS unit because they're concerned the patient might become dependent on an opiate pain reliever.
ADVANCE: Are there any conditions for which you would say e-stim is either contraindicated or there would be no real benefit?
Tutt: If somebody has any numbness or something like that. There are different levels of applying the TENS. We typically use a sensory. You can get into motor stimulation, it's going to be a little more aggressive and actually painful. So if somebody has sensation deficits in that particular area, I definitely wouldn't use it. Anybody with a pacemaker is definitely contraindicated as well.
ADVANCE: You've been in the field for 13 years. Do you have an opinion on whether e-stim is used enough by physical therapy professionals in general?
Tutt: I tend not to get into what other therapists are doing. There are so many different pathways to accomplish the same goal and this is one of the pathways that I choose to use. I see therapy really as a customer-service business firstthat's kind of my philosophy. You use therapy modalities to serve the patient and I think any time therapy can provide relief to somebody who's in pain, it's going to be beneficial. That's why I tend to use it maybe a little bit more. None of us like to be in any sort of pain, so when we can do anything to relieve the pain, especially through non-pharmacologic methods, I'm all for that.
Brian W. Ferrie is senior associate editor at ADVANCE and can be reached at firstname.lastname@example.org