User:Tmarovino/sandbox

Rehabilitative or Ultrasound Imaging in Physical Therapy

In 1997 the use of ultrasound imaging for Physical Therapy within the context of differential diagnostics was born in Allen Park, MI. Prior to that time, Australian physical therapy researchers had been experimenting with using diagnostic ultrasound imaging (DUI) primarily within a biofeedback design, providing patients a visual feedback element while activating core pelvic musculature. To that point, no other physical therapy applications had been explored, or at least, no other applications had been published. The use of DUI as a primary physical therapy diagnostic intervention had it's genesis as part of a larger set of policy, legislative and insurance reimbursement reforms that were occurring simultaneously. Legal reform combined with changes in third party reimbursement criteria for soft tissue injury reimbursements to medical providers. The resulting new soft tissue injury threshold that was created demanded better documentation and a generally higher soft tissue injury evidence standard. Concurrent to this was that the era of fee for service was at a peak, with physician/hospital reimbursements climbing and contributing to out of control health care expenditures. Managed care and all it's cost containment measures were being touted as inevitable and the likely savior of this runaway speeding train referring to health care expenditures. Physicians, mostly radiologists, had experimented with DUI but the dubious resolution (at the time), poor relative reimbursement, high operator dependency and necessity of employing an ultrasound technologist to harvest the exam, relegated DUI to the bottom of the imaging totem pole. As radiology physicians essentially discarded this modality, other clinician groups began to gradually experiment, and eventually adopt DUI for their specific professional applications including physical therapists, chiropractors, podiatrists, and more recently, rheumatologists, occupational medicine physicians and orthopedic surgeons.

In the early 1990's an Allen Park, MI clinical group, which included several physicians, a chiropractor, a physical therapist, and several athletic trainers began experimenting with DUI. The physical therapist assigned to learn about this modality was Tiziano Marovino PT, a clinical research therapist who would then go on to champion the use of DUI in physical therapy. The Allen Park group was an early adopter of DUI within the no fault (auto injury) environment and experienced immediate success in being able to better document soft tissue injuries with subsequently improved insurance reimbursement. Over the years, DUI has evolved as a technology with better resolution capabilities now available for less cost. Dr Tiziano Marovino continues to be the pioneering PT clinician that works to promote through studies, publications, presentations and workshops, how PT's benefit when using DUI in orthopedic/sports physical therapy. Dr Marovino first published a call to arms to the PT profession in 2003 (Advance magazine) with the message being "dare to imagine" what it would be like to have a safe and reliable imaging technology available in our examination toolset. The first PT specific workshop was conducted also in 2003 at Creighton University in the tDPT program attracting therapist participants from both Nebraska and Kansas. Dr Marovino was the first PT in the US to study/publish, along with clinically using and receive direct and indirect insurance reimbursement for DUI. Until more recently there were no structured educational routes for PT's to learn about DUI other than the handful of PT published reports available to that point in time. In 2012 the American Registry for Diagnostic Medical Sonography (ARDMS) the credentialing agency for ultrasonography in the US decided to construct an exam and registration specifically for clinicians interested in musculo-skeletal ultrasonography (RMSK). Physical Therapists are eligible to qualify for that exam which is the gold standard certification that demonstrates competency in MSK US scanning. Since Physical Therapists in most jurisdictions of the US now enjoy direct consumer access to their services, it is logical that PT's have technology such as DUI to optimize their diagnostic responsibilities to both the patient community they serve, as well as, the referring physicians who rely on PTs to properly evaluate a patient condition. Physical Therapists are expected to recognize the severity of a condition so as to safely engage a patient in effective therapeutic exercise. The PT care plan begins with an accurate PT diagnosis and the use of DUI within a PT practice allows for significantly improved differential diagnosis as per APTA mandates regarding the diagnostic expectation of a PT. DUI was a platform presentation topic at the World Congress of Physical Therapy 2015 in Singapore which won the congress best presentation award for North America/Carribean region. Dr Marovino was the speaker for this seminal presentation providing scientific evidence that supports DUI use in a PT practice, and that the test interpretation made by the PT closely matches that made by a radiologist using MRI for rotator cuff tears of the shoulder (Marovino, Caffo 2010). The use of DUI in PT can be quite distinct from how an MD/DO might use this same technology. The PT is less interested in diagnosing classical disease/pathology and more interested in injury/disease induced signs and symptoms such as swelling, masses, foreign bodies, tears, elongation injury and other structural abnormalities. Structural, mechanical and bio-physical alterations in the human body have a multitude of manifestations that certainly can lead to MSK pathology and chronic pain if left untreated. Using DUI to recognize (early detection), categorize (diagnostic classification), and generally help guide (serial monitoring) the treatment planning of a patient is invaluable. Furthermore, the increased emphasis on functional outcome measuring to help identify, define and estimate the magnitude of incremental patient progression or improvements lends itself well to the use of DUI for that historically elusive visual confirmation. Imaging is a powerful diagnostic, prognostic and screening tool so to have a readily available, inexpensive and safe modality on hand that can deliver these attributes is literally a game changer for the PT profession. The transformative potential of DUI to PT's was forseen in those early days in the mid 1990's and so the quest to "train the trainers" began shortly thereafter. The rest is the natural unfolding of a technology phenomenon that has been unleashed and takes on its own destiny with key practitioners then taking the lead to spread utilization and hopefully create new pathways and applications for DUI.

Common PT Applications: Early injury detection is an important DUI feature and advantageous in the workplace environment. This is arguably one of the most common sense and seemingly cost effective applications for the use of DUI, yet probably the application that is least used. Prevention has not been much more than a political talking point in the more general conversation of health care. Prevention has lacked appeal in the current US health care system partly because we have created a health system based on tertiary care-a sick care system that is reactive as opposed to proactive regarding injury/disease prevention. We focus on disease or injury only after symptoms have started, rather than allocating resources to try and prevent injury or disease. Our fee for service payment model reinforces the practitioner for service intensiveness and encourages over utilization. New payment models that focus on cost containment with emphasis on practitioner performance (pay for performance), patient outcomes and overall value will prevail in the new era of health care reform. Organizational imperatives are changing (paradigm shift) with greater emphasis on accountability and patient engagement with the overarching goal being the provision of the highest quality of care at the lowest per unit price that can yield optimal patient experience. The new dialogue includes a greater emphasis on prevention, but implementation policies at the organization/institution/health system and company level seem too often to move forward with glacial swiftness. The ROI of prevention programs have traditionally been an elusive metric to measure unlike the costs of services rendered for an episode of care which are more easily identified.

The use of DUI in the Physical Therapy space is growing rapidly, more so in other countries, but significant in the USA as well. The emergence of special interest groups (SIG's) at the state and national levels along with for profit PT owned and operated continuing education companies are helping to expose a greater number of practicing PT's to the possibilities of DUI. Physical Therapists are now able to qualify to sit and pass the ARDMS national examination which if successful, will confer the RMSK(s) certification designating the holder as credentialed in MSK ultrasonography- the highest level of certification available at this time. There are now formal training pathways for interested Physical Therapists to gain knowledge and experience in Ultrasonography and US liability insurance is now also available to those who hold the RMSK(s) credential. The term "rehabilitative imaging" has been used recently in reference to DUI used in Physical Therapy and is synonymous with MSK DUI and merely references the setting in which DUI is being used. It does not change what DUI is and likely always will be- a cost effective, safe and versatile form of imaging available to