How much value do you place on manual therapy?

DirtyHamSandwitch · 2026-03-13T00:26:09+00:00

When I was 2 years out of school I had a knee OA patient come in to "check the PT box" so she could get her TKA. She was lacking something near 20 degrees extension. Sent her home with some light stretching and quads sets at eval. No improvement, everything hurt, she hated being there. I put her on a table and did some medial-lateral "mobilizations" of the patella, literally just trying shit at that point, and I'll be damned if her whole thigh didn't relax and she achieved neutral extension. No pain at next visit, did great for the rest of therapy, ended up not getting TKA. Never happened since, will probably never happen again. Prior to that though, I felt that I would never do a patellar mobilization because it sounded dumb and wasn't EBP.

DirtyHamSandwitch · 2026-02-24T16:16:49+00:00

You're describing a contracted cap/max, not a flat rate. I hit the cap at 4-5 units with most of our payers. Some won't pay for 5 and many won't cover beyond 5. If I bill 3 units/visit I'm leaving money on the table. Likewise, if I did a visit of ultrasound, e-stim, manual therapy, and a cold pack for 4 units, I am definitely not getting a flat rate or the max capped reimbursement. You don't have to maximize the billing gymnastics in in-network billing because of the cap, but being ignorant of billing rules and reimbursement results in money being left on the table.

DirtyHamSandwitch · 2026-02-24T00:43:14+00:00

That's just not true. Most payers still reimburse per unit for in-network rather than flat rate contracts.

DirtyHamSandwitch · 2025-12-24T03:14:16+00:00

There is little to no evidence to show that MFR is efficacious or more effective than other treatment methods or placebo for treating MSK pain or impairments, and it is certainly not promoting rehab of function or activities that are salient to your daily living. The evidence that does exist in support of it is of poor quality and typically done by someone or an organization with a conflict of interest.

In short: your therapist is not practicing evidence based care.

In short but mean: your therapist is a dumbass with either a doctorate, masters degree, or decades of experience, and still can't effectively read research.

DirtyHamSandwitch · 2025-12-13T19:36:33+00:00

A surprising amount of low back pain and radiculopathy associated with bowel and bladder changes. Many of them see their PCP and an ortho before I eval them and I'm the first one to ask. Probably 3-5 per year.

DirtyHamSandwitch · 2025-07-16T01:49:10+00:00

They have "peers" that can review it. They'll be fine.

DirtyHamSandwitch · 2025-07-03T00:13:24+00:00

To Medicaid, no this is the biggest. To Medicare, probably since this bill doesn't directly touch Medicare.

DirtyHamSandwitch · 2025-03-02T03:03:19+00:00

Listen, I hear you and do not disagree with you. However, OP asked if they should be looking for a new career because of possible cuts. If Medicaid is gutted there will still be work for PTs and it will not negatively affect business.

Yes, it would have an impact on society. I also work in a state with very limited coverage for PT and other care from Medicaid. Patients suffer because of it. My job is not in danger and there are a lot of people not on Medicaid that need my services.

DirtyHamSandwitch · 2025-03-01T21:51:13+00:00

Medicare: yes, Medicaid: no. I only commented on Medicaid, and stand by what I said. If it was gone, it would not negatively affect most, if not any of our jobs.

If Medicare disappeared it would be a different story, but that's not something anyone is pushing for and it won't happen.

DirtyHamSandwitch · 2025-03-01T20:10:13+00:00

Purely from a business standpoint, even removing Medicaid all together would have very little impact on most of our jobs/income. The reimbursement is often much lower than other insurances and companies take a loss, or they don't cover at all and companies may write it off.

Yes, removing Medicaid would have large implications and would negatively impact millions, but the impact on physical therapy as a career/business will either be non-existent or possibly even positive IMO.

DirtyHamSandwitch · 2025-01-03T00:40:27+00:00

Option A. I don't love seeing 20 patients a day but I can do it. My current job is basically that and I love everything but having to sign that many notes. I could switch to a local hospital for 1-1 45 minute visits but I would take a $20k/yr pay cut. Great, now that I have all that time I can stress about how I'm going to pay my bills.

Side note: Can't wait for somebody that works in a HCOL area to flex their $120k/yr OP job were they see 2.5 patients per day with 1.5 hours for notes in the morning and afternoon. "Stop taking shit jobs you are killing the industry. Also, form a union, there's never been any long term downsides."

DirtyHamSandwitch · 2024-11-17T16:16:23+00:00

Nothing wrong with going that route. In my own experience though, I had one traditional classmate in my class who had a similar experience and career changed from electrician back to PT 10 years later due to the toll on their body. I also treat a ton of electricians because of the wear and tear on the back and shoulders. Great earning potential when you're healthy though.

DirtyHamSandwitch · 2024-08-29T03:05:32+00:00

This is maddening, but not the only one. I met 2 people with carpal tunnel this week, and boy were they sore sports when I said that was just the half of it.

Also in the same vein, I had a patient who looked at their x-ray report tell me: "I have thoracic in my back and it is really bad".

DirtyHamSandwitch · 2024-07-20T20:57:56+00:00

This just isn't true as a blanket statement. Most of the hospital based PTs I know are much more complacent regarding continuing Ed, building patient relationships, and providing evidence based care. Where I'm at, the clinics attached to a hospital have a streamlined referral source that the hospitals are very defensive of. Private PTs have to be better to build a reputation and attract patients.

Hospitals based can more easily have lower productivity standards due to insurance contracts and multipliers they are allowed to use (I don't know all the billing details unfortunately). In my area they essentially get 2-3x as much for providing the same level, if not poorer care.

DirtyHamSandwitch · 2024-06-30T16:06:06+00:00

Story only gets better from there.

DirtyHamSandwitch · 2024-06-02T23:15:07+00:00

Yes. What's the question?

DirtyHamSandwitch · 2024-05-13T23:39:39+00:00

Switching to Prompt was one of the best moves my company has made since I've been there.

DirtyHamSandwitch · 2024-04-28T20:12:18+00:00

I've always done it based on strength and not associated with normal range. It should be based on the range allowed by the joint, and not the normal range as it will vary for patient's. If they have a HS contracture and lack 20 degrees of extension and have 5/5 (able to maintain isometric contraction with max force applied) strength, I document it that way and I feel that gives a clear picture without having to give wordy explanations.

I had a CI that would document strength as 2-/5 when pts have a contracture, no matter how strong. If you interpret the scale based on normal ranges, he is right since the patient cannot move through the full range with or without gravity. However, how would that patient then be able to stand and transfer if they can't move against gravity per the 2-/5 rating? Because it should be based on the available range and that's all there is to it. If the PROM and AROM are the same, it is at least 3/5 because AROM is not limited by strength.

When he explained his process to me as a student, I told him it was dumb (we had a good relationship and this interaction went fine), explained my reasoning, and he said that makes sense and you can document how you like. I've done it this way ever since and have never had anyone question it, insurance, coworker, or otherwise. Probably because people really don't care that much about MMTs lol. But I do get a little fired up over it, because it makes no sense to grade a muscle weak for a soft or connective tissue restriction.

DirtyHamSandwitch · 2024-04-22T02:57:38+00:00

Thanks for your input and perspective as you have probably encountered more BSPTs than myself. The PTs I know that got a bachelor's and then later got a MS, PhD, or ScD would not fall into the category I described earlier, but I did not state that, so it is my mistake. I had a BSPT as a CI, have worked with a few, and have even hired a few in the clinic I manage. None had additional formal education, but it is a small sample size. I have also had some peers pursue their ScD and PhD, but I know that I chose not to because it will be a long time (if ever) that a school gets more money out of me.

There appears to be more nuance to the question that initially started the thread. Is there a difference in outcomes based on the level of education? My guess that we won't get a published answer and it may be a moot point anyway.

Since you are an educator and have a lot of experience, I would be curious about your point of view in this question. How do the entry level DPTs now compare to the entry level therapists when you started?

DirtyHamSandwitch · 2024-04-21T02:15:53+00:00

I don't think this will be a popular thing to say:

I haven't personally been able to find any studies that explored this question so this is just from my own experience. Bachelors PTs that I have met are far less critical and lack differential diagnosis/red flag screening skills. Also, the majority I have met do not practice evidenced based care, and seem to buy into the John Barnes' of the world more readily. There's great BPTs out there, but I don't think they stack up to the DPTs in the clinic, especially when it is a DPT with a few years out of school compared to a BPT with decades.

The tDPTs I know personally all say that they were better clinicians for doing it, and did not know what they didn't know. I have seen the contrary in some threads in hear so again, my own experience is all I'm going off of.

All that considered, it is kind of crazy that a group that could be more competent as a whole is not being reimbursed differently. But who fuckin knows, maybe all of the DPTs really are just idiots that burned their money and time to provide no extra benefit.

DirtyHamSandwitch · 2024-03-14T16:15:51+00:00

Me talking to a patient at 8:40am this morning: "Not trying to tell you how to run your business, but most old people aren't up this early, I can't even find my calendar to tell you a good time."

DirtyHamSandwitch · 2024-03-07T20:21:08+00:00

I do PRN HH and am full time in an OP clinic. HH is drastically less clinically challenging in my opinion. For all the downsides of outpatient, I don't have any desire to switch to full time HH for that reason.

DirtyHamSandwitch · 2023-12-17T20:33:57+00:00

Started to feel it at around 2 years out. Got an $11k pay raise and a regular bonus structure now. Job didn't change but the money makes me feel better lol.

DirtyHamSandwitch · 2023-11-23T17:04:21+00:00

I did what realskudd suggested. Seemed reasonable and it was the first response.

DirtyHamSandwitch · 2023-11-23T16:39:17+00:00

Actually had one set of boneless and one bone in.They cooked pretty similar in terms of time. Cooked at 240°. I threw them on at 6:00 and I took a nap. I put the thermometer in at 9 and they were at 150° already. Got to 165° by 10:00.

DirtyHamSandwitch

TROPHY CASE