Why can’t I just get a prescription for physical therapy

Posted by artsy6013 @artsy6013, Apr 10, 2022

Sometimes I wonder if doctors are in cahoots. I went to see my primary last week to ask for a prescription for physical therapy. I have had degenerative disc disease for some years now. My doc has a bunch of x-ray and MRI results on hand. So I don’t understand why she is making me get another x-ray before she will write me a script. I am okay to do this but I feel I would really benefit from physical therapy now while I am waiting for my appointment with the radiology center. I kind of feel like she is milking it by sending me for x-ray so she can schedule me to come back for another appointment with her. I feel like I am living to see doctors 😞

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@artsy6013 I think your doctor is being cautious because your spine condition could have changed since your imaging was done. For example, if you have one vertebrae slipping past another one which they call spondylolisthesis, that could be a situation where a physical therapy exercise maneuver may not be safe for you to do. One good example would be if a person had this instability at the skull/spine junction. My physical therapist told me that working on the neck with this type of instability could be paralyzing or even fatal. She requires that kind of information and diagnosis before beginning therapy work with a spine patient. With spine issues, imaging within a year is considered current. This is a safeguard for you as well as good practice for your physician. It may also be needed to justify insurance payments for your physical therapy.

Have you been able to manage your spine symptoms with exercise? I am a spine surgery patient, and my surgeon told me the best way for me not to need his services again is to maintain core strength. It also helps because it takes less effort to stack the vertebrae with good posture than with poor posture.

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@jenniferhunter

@artsy6013 I think your doctor is being cautious because your spine condition could have changed since your imaging was done. For example, if you have one vertebrae slipping past another one which they call spondylolisthesis, that could be a situation where a physical therapy exercise maneuver may not be safe for you to do. One good example would be if a person had this instability at the skull/spine junction. My physical therapist told me that working on the neck with this type of instability could be paralyzing or even fatal. She requires that kind of information and diagnosis before beginning therapy work with a spine patient. With spine issues, imaging within a year is considered current. This is a safeguard for you as well as good practice for your physician. It may also be needed to justify insurance payments for your physical therapy.

Have you been able to manage your spine symptoms with exercise? I am a spine surgery patient, and my surgeon told me the best way for me not to need his services again is to maintain core strength. It also helps because it takes less effort to stack the vertebrae with good posture than with poor posture.

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Hi Jennifer. Thanks for your response. What you are saying makes a lot of sense. Too bad my doc didn’t provide an explanation like this. It certainly would have been more helpful. I have had relief through physical therapy in the past and I still use the exercises I learned in therapy but they are not working the way they used to. I also have a TNS nerve stimulation wrap that I can synchronize to my iPhone and adjust the intensity of the stimulation. I also use hot/cold therapy and every day for at least 15 minutes. All of these efforts are becoming less successful in managing the pain. I will get the X-ray this week but I still feel like I am on the doctor merry go round.

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My experience is that the doctor just issues a referral to a PT and not a prescription.

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It’s very common for docs to write a PT prescriptions to “Evaluate and Treat” the patient. This way you receive an evaluation from a therapist who may potentially treat you too. And their knowledge of human body mechanics except for a few docs are pretty good in my opinion. Good luck with your care.

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@kenc

My experience is that the doctor just issues a referral to a PT and not a prescription.

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PT's in my area require a prescription.

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@windyshores

PT's in my area require a prescription.

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May have something to do w/ your insurance?

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This is a timely topic for me. I am about 4 months post C3-C6 ACDF and still have bilateral arm and (especially) hand pain. Per surgeon basically in "wait for nerves to heal" mode. But I have noticed that certain movements greatly affect my pain… e.g. while sitting if I simply clasp my hands behind my head (like doing a stretch), that causes burning pain in my arm and (mostly) my hand. Also, laying in bed, placing my right arm out 90 degrees and rotating my hand caused another flash of pain in my forearm and hand.
My experience with physical therapists is that they are usually great at understanding the complex web of muscles, ligaments, etc. and how they work.
Since my ACDF surgery has not relieved my pain (I know it can take up to a year or more), is it reasonable for me to at least ask for a PT to diagnose this, almost as if they did not know my surgical history? FWIW my surgeon has not really been responsive to any suggestion about any other root cause(s), such as TOS or carpal tunnel.
Finally, I should add that my history of both lumbar and CT scans (cannot have MRI due to pacemaker) show severe stenosis pretty much everywhere. They are not sure if it is normal aging or if it could be congenital.

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@birdman518

This is a timely topic for me. I am about 4 months post C3-C6 ACDF and still have bilateral arm and (especially) hand pain. Per surgeon basically in "wait for nerves to heal" mode. But I have noticed that certain movements greatly affect my pain… e.g. while sitting if I simply clasp my hands behind my head (like doing a stretch), that causes burning pain in my arm and (mostly) my hand. Also, laying in bed, placing my right arm out 90 degrees and rotating my hand caused another flash of pain in my forearm and hand.
My experience with physical therapists is that they are usually great at understanding the complex web of muscles, ligaments, etc. and how they work.
Since my ACDF surgery has not relieved my pain (I know it can take up to a year or more), is it reasonable for me to at least ask for a PT to diagnose this, almost as if they did not know my surgical history? FWIW my surgeon has not really been responsive to any suggestion about any other root cause(s), such as TOS or carpal tunnel.
Finally, I should add that my history of both lumbar and CT scans (cannot have MRI due to pacemaker) show severe stenosis pretty much everywhere. They are not sure if it is normal aging or if it could be congenital.

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@birdman518 Hi Mitch. It sounds like your surgeon is not familiar with TOS, and if he were to acknowledge the possibility of TOS, he would be acknowledging that he missed it when he diagnosed you. I would guess he wouldn't want to admit he missed something especially when it has overlapping symptoms with the spine condition you did have affecting the same nerves, but in different places. I had that problem too with a surgeon who missed TOS, and it didn't go well when I pointed out the mistake. Surgeons never want to make mistakes let alone admit that to a patient. These are things he should have ruled out as a differential diagnoses so he could say with authority that your symptoms were spine related before doing surgery. That being said, your imaging clearly showed stenosis that is definitive for problems of nerve compression, and with overlapping symptoms both of these issues can contribute to the whole problem.

What you describe is consistent with thoracic outlet syndrome in that raising your arms and the same degree of this when laying down brings on symptoms. Rotating your hand is flossing the nerves in those positions. Posture is really important for TOS. What happens with me is I over use my traps raising my shoulder and my shoulder blade muscles are not doing their job keeping the shoulder pulled back where it should be, so my shoulder rotates forward as a "normal " position for me. My PT is having me do exercises to pull the shoulder back and downward. Take a look at your standing posture in a mirror from the side. Your shoulder should be directly under your neck; not forward. Is your head in a forward position or can you hold your neck in a vertical position? I see my husband do this of slouching forward with a forward head position which I describe as looking a bit like a turtle with its neck sticking out.

You may have more luck approaching a neurologist or a thoracic vascular surgeon for a diagnosis of TOS and/or getting a script for PT. They probably would still defer to your spine surgeon to say that PT is safe for you at this time during post surgical healing. I would pick one at a different facility who doesn't know your surgeon because they probably would not want to challenge a diagnosis if they work with your surgeon, and I would ask if they have worked with a lot of TOS patients and saying that you think you need to be tested for this. 4 months is a normal time to begin PT after spine surgery if you have a fusion that has begun fusing, and that is when I started PT after my spine surgery. Can you do some things to stretch the front of your chest? With TOS this gets too tight. I use a foam roller and lay on it on my back (you can find them online.) I don't know about your abilities or what you can safely do, so it's your call, and as always, check with a medical professional. You can also stretch one side at a time on a bed or couch and just let the weight of your arm stretch off the side. Myofascial release may help too anyway. Sure, your nerves need to heal, and any compression of them in other places is not going to help.

Can you find a medical facility that lists TOS as a condition that they treat? You can probably find a specialist there.

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Jennifer, thanks as always for your thoughtful and detailed replies! The only PT I have had so far was because of my C5 nerve palsy, which thankfully has mostly cleared up. Before, I could not lift my right arm. Now I can, with the caveat about the continuing nerve pain in my hand afterwards.
I remember my surgeon stating that PT for my post-surgery would have to wait a while… I do see him on June 7, and will basically revisit my post with him there. If he is willing for me to continue PT I will try to get to the bottom of what my ongoing issues are. Remember that the surgeon is stating that the recovery from any nerve damage that had been caused pre-ACDF could take a year.. and that pretty much matches what everyone online says.
I know that posture is important, and I probably do not have good posture. I have been trying to work on it.
My research so far on TOS (including your posts) pretty much do NOT indicate that there is a simple fix… clearly I had bad spine issues before based on my CT scans… there seems to be no comparable definitive diagnosis for TOS.. or am I wrong?

Thanks again,
Mitch

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@birdman518

Jennifer, thanks as always for your thoughtful and detailed replies! The only PT I have had so far was because of my C5 nerve palsy, which thankfully has mostly cleared up. Before, I could not lift my right arm. Now I can, with the caveat about the continuing nerve pain in my hand afterwards.
I remember my surgeon stating that PT for my post-surgery would have to wait a while… I do see him on June 7, and will basically revisit my post with him there. If he is willing for me to continue PT I will try to get to the bottom of what my ongoing issues are. Remember that the surgeon is stating that the recovery from any nerve damage that had been caused pre-ACDF could take a year.. and that pretty much matches what everyone online says.
I know that posture is important, and I probably do not have good posture. I have been trying to work on it.
My research so far on TOS (including your posts) pretty much do NOT indicate that there is a simple fix… clearly I had bad spine issues before based on my CT scans… there seems to be no comparable definitive diagnosis for TOS.. or am I wrong?

Thanks again,
Mitch

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Hi Mitch,
In your post you mention that you're working on your posture. So am I for my several back issues: osteoporosis, multilevel degenerative changes, disc herniations loss of disc height, central canal stenosis, foraminal narrowing and nerve compression.

This book was recommended and I am finding it very helpful: Back Mechanic, The secrets to a healthy spine your doctor isn't telling you. The author is Stuart McGill Phd. You can also find him on YouTube. I'm taking classes with a McGill trained and certified practitioner. Progress is slow but worthwhile.

All the best,

Diana

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