• Ethics in Practice

    Energy Crisis?

    Use of a certain technique leads to questions.

    Dictionary.com defines the letter of the law as its "precise wording"—as opposed to its "spirit or intent." Sometimes a dictate's wording is imprecise—inviting exactly the sort of "letter"-versus-"spirit" conflict around which the following scenario revolves.

    Physical therapists (PTs) are motivated by their desire to do everything in their power to relieve pain, restore function, and help patients and clients live their lives to the fullest. But the ability to change lives is accompanied by the need always to consider the evidence and heed applicable laws. Consider the ethical responsibilities of the 2 PTs in the following scenario.

    An Alternative Approach

    Cindy is a "float" PT for a large health care system with numerous outpatient clinics, filling in for other PTs who are on vacation or leave. She enjoys the opportunity to work at various facilities, constantly meet new people, and treat patients who present with an array of conditions.

    When she gets the call to fill in for a PT at Riverview East who's going on maternity leave, however, Cindy welcomes the opportunity to stay in 1 place for several weeks. Jim, the facility manager and the other PT on the premises, introduces her to the staff and shows her around. He'll see patients in one treatment room, he tells Cindy, and she'll use the other one.

    Cindy's second patient that day is Ruth. The 64-year-old has pain that is radiating from her right knee to her right foot and is affecting her balance. She's always been active, and she's eager to return to her daily walking regimen. "This issue has flared up before," she tells Cindy. "Physical therapy always has worked—eventually. I just wish there was some way to resolve the pain issues a little more quickly!"

    After conducting a thorough examination, Cindy shares an idea.

    "I recently achieved certification in an alternative treatment method that I believe can address the root cause of your pain," she says. "I think it can be a valuable adjunct to physical therapy in your case. But I haven't tried it on a patient before. Do I have your permission to do so?"

    "Absolutely!" Ruth responds. "The sooner I can resume my daily walks, the better. I take my fitness very seriously."

    "Great!" Cindy says. "As long as you have an open mind. I'll be tapping energy fields that surround your body and affect your pain centers. I won't be physically touching you. But during my training I saw some great results with this technique, and I've studied up on it quite a bit."

    "I'm very open to new approaches," Ruth assures the PT. "I've heard of something that sounds sort of like that. Reiki? Is that what you're talking about?"

    "No," Cindy says. "But it's also of Asian origin, and some of the principles are similar. It's still considered 'experimental' in some quarters. Anyway, what do you think?"

    "Sure," Ruth answers. "I'm fine with it."

    Cindy incorporates the technique into the treatment session. Afterward, Ruth describes her pain level as 4 on a scale of 10—compared with 8 when she arrived at the facility. "I think you're making a believer out of me!" she says.

    Cindy documents the session as having included 2 units of Current Procedural Terminology (CPT) code 97140—manual techniques. "It seems as if, just as I'd expected, I've added a valuable tool to my toolbox as a PT," she thinks to herself.

    Over the remainder of the week, Cindy incorporates the alternative procedure into her treatment plan for several other patients, with similar reported results. On Friday, Jim happens to step into the room while Cindy is performing the technique. Later that day, he calls her into his office and asks what she was doing. Cindy discusses the matter with him at length, assures him that she's certified in the procedure, and encourages him to check into it if he has any doubts. She refers him to a few websites.

    What Jim finds—or, rather, doesn't find, on those sites and in literature searches—troubles him. Beyond the website of the organization from which Cindy received her certification and another one that describes various alternative treatment methods that have Asian origins, he finds few online references to the technique, period—let alone any research data. And it greatly discomfits Jim that Cindy is billing the practice as a "manual" technique despite the fact that she's making no physical contact with patients while performing it.

    The subject preoccupies Jim over the weekend. He feels that he must revisit it with Cindy sooner rather than later. The first thing Monday morning, he resumes the conversation.

    Jim shares his concerns about the lack of evidence and the questionable documentation. Cindy responds that her mentor in the technique is an American PT who'd learned it from some of the "masters" overseas. "It's had practitioners in Asia for several years now and has been found efficacious for both acute and chronic pain," she says. "Can I show you an awesome PowerPoint presentation that I think you'll find instructive?"

    Jim is dubious, but he follows Cindy over to her computer. What he sees on her screen are a lot of impressive claims, but not 1 peer-reviewed reference or any evidence of outcome studies or ongoing clinical trials. He point this out to Cindy, but is a bit taken aback when she forcefully responds, "Look at what's happening in Asia! What about my patients' reported pain reduction? And there really are no contraindications! I'd argue that a clinical trial is already under way right here at Riverview—and that it looks very promising. "

    Cindy's "reported results" have more than a whiff of "placebo effect" to Jim, and he doesn't give much credence to scientifically undocumented claims from overseas. Still, he's not quite disposed to categorically dismiss techniques that patients say are helping them. He recalls how, before he'd discussed the technique with Cindy the previous Friday, he'd seen Ruth as she was leaving the facility and she's raved about the reduction in her pain in just a week's time. Jim is well aware that some techniques that once seemed "out there" now are accepted aspects of physical therapist practice.

    He thanks Cindy for her input and says he needs to give the matter some thought. After she leaves the room, he's left alone with some big questions. Can he permit care to continue that has no basis in scientific evidence? Even if he were to do so, how should it be billed? Should this "experimental" alternative procedure be billed to a third-party payer at all?

    For Reflection

    Have you encountered questionable practices related to a particular intervention during your career? If so, did you address them in some way? Why, or why not? If you did take action, what did you do?

    For Followup

    I encourage you to share your thoughts about the issues raised in this scenario by emailing me at kirschna@shp.rutgers.edu.

    If you are reading the print version of this column, go online to www.apta.org/PTinMotion/2017/5/EthicsinPractice/ for a selection of reader responses to the scenario, as well as my views on how the situation might be handled. If you are reading this column online, simply scroll down to the heading "Author Afternote."

    Be aware, however, that it generally takes a few weeks after initial publication for feedback to achieve sufficient volume to generate this online-only feature.

    Kirsch, Nancy 75x110

    Nancy R. Kirsch, PT, DPT, PhD, a former member of APTA's Ethics and Judicial Committee, is the program director and a professor of physical therapy at Rutgers University in Newark. She also practices in northern New Jersey.  


    At www.apta.org/EthicsProfessionalism/:

    • Core ethics documents (including the Code of Ethics for the Physical Therapist and Standards of Ethical Conduct for the Physical Therapist Assistant)
    • Ethical decision-making tools (past Ethics in Practice columns, categorized by ethical principle or standard; the Realm-Individual Process-Situatison [RIPS] Model of Ethical Decision-Making; and opinions of APTA's Ethics and Judicial Committee)

    At www.apta.org/PTinMotion/2006/2/EthicsinAction/:

    • "Ethical Decision Making: Terminology and Context"

    Considerations and Ethical Decision-Making

    Jim poses several important questions regarding the use of a technique that is not well-vetted, and about how the technique is being represented in documentation. Cindy supports the procedure, and suggests that its anecdotal efficacy will yet be supported by scientific evidence. She doesn't address the documentation aspect, but she presumably believes that tapping energy fields with her hands constitutes a "manual" technique.

    Realm. The realm is organizational/institutional, in that Jim, as facility manager, is obliged to ensure that patients are treated safely and effectively, with interventions backed by data that justify their inclusion in the physical therapy plan of care. Cindy's actions are governed by the individual realm. Is the technique within her professional, regulatory, and personal scope of practice? Is it of lasting benefit to her patients?

    Individual process. For Jim, moral judgment is required—he must decide between right and wrong actions. If he does not feel the intervention is appropriate as employed and documented, he must insist that she discontinue its use. Cindy needs moral sensitivity—the ability to recognize, interpret, and frame the situation in ethical terms.

    Ethical situation. This is a moral issue for both Jim and Cindy—a situation in which important moral values are being questioned. Is it to the patient's best benefit for her therapy time to be spent on a technique that is not grounded in evidence? Is the code for manual techniques being misused?

    Ethical principles. The following principles of the Code of Ethics for the Physical Therapist offer Jim and Cindy guidance:

    • Principle 4A. Physical therapists shall provide truthful, accurate and relevant information and shall not make misleading representations.
    • Principle 6C. Physical therapists shall evaluate the strength of evidence and applicability of content presented during professional development activities before integrating the content or techniques into practice.
    • Principle 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.

    Author Afternote

    This scenario generated a great deal of response. Readers emphasized the importance of evidence-based practice—citing principles 4A and 6C of the Code of Ethics for the Physical Therapist (see the "Considerations and Ethical Decision-Making" box)—and the need for accurate documentation and billing of all provided services. There was considerable disagreement among respondents, however, about what constitutes "good evidence," and whether and how techniques that lack substantial evidence should be integrated into practice. A related subject was variations in practice, with readers generally agreeing that the problem is not variations in and of themselves but, rather, differences in quality and effectiveness among techniques used.

    A few respondents felt the scenario cast aspersions on non-Western medicine. That was not the intent. I’ll note here that the technique referenced in the scenario was pointedly and deliberately unidentified, and it was not meant to be equated with any specific, actual technique.

    There was uniform agreement among responders on 1 point: the need for strong communication between and among health care providers regarding all services provided to patients.


    One should never create or innovate or develop a new technique or approach. If you're the first one doing it, it means there's no prior evidence for it. Therefore, don't do it. Only do it if it's evidence based. All other actions will cause the wheels of the universe to grind to a halt and all mankind will suffer as a consequence. j/k Good subject actually. It also makes a good case for why an insurance based healthcare system where everything has to be coded into a particular category and everything has to be justified to some insurance company or government institution with management or executives who use their bureaucracy against you has led to the development of a sick and perverse system that should be put out of its misery.
    Posted by Brian Miller -> =KX[> on 4/29/2017 10:52:20 PM
    There was two aspects here. First of all, indeed we should only practice new methods if there is enough evidence to support the claims. There should be a foundation of research, ideally RCT's and double blind studies, not anecdotes, to warrant the use of the new method. On the flip side, I have personally dug into the research on energy medicine and I have come to the realization there is sufficient evidence to support the use of energy medicine. Even the government, through the National Institute of Health, is doing research on this topic. I know of several PT's who successfully practice a form of energy medicine, such as Prana, Quantum Touch, RH, etc.. That on its own doesn't justify it of course, but these practitioners have also extensively researched this type of treatment. There are numerous renowned people such as Carol Davis EdD, PT, Richard Gerber MD, Gary Schwartz PhD, James Oschman PhD, David Feinstein, PhD and many more, that have written books and other publications about this interesting topic. Only because we have always done a certain way, doesn't make it right. When I started my training back in the 70's all ACL repairs were casted; now a surgeon would get sued if he'd do that. Currently, many patients with meniscal damage undergo arthroscopies. However research doesn't support this, still this type of practice continues. Personally, I am on both sides of the coin. I advocate solid research to build a better foundation; at the same time I advocate that practitioners keep an open mind and get educated on this topic. Just "like back then" when people thought the earth was flat, maybe they may consider the earth is round.
    Posted by Jos Dorrestein, PT, MHS on 5/11/2017 2:08:58 PM
    Interesting article, unfortunately exploring new treatment methods that have not yet been vigorously researched and shown to be effective is nearly impossible when billing a third party payor. Insurance companies have become very specific in what they will pay for. Maybe billing patient directly or a code other than for manual therapy would be more appropriate.
    Posted by Karen Rafferty -> >NV_
    Of course its unethical. "Dry Needle" is the unstated technique in this article. It is unethical for Physical Therapist to be practicing dry needle for a number of reasons.
    Posted by dr. evan mahoney on 5/26/2017 9:59:07 AM
    As noted by the author, this article "is not meant to be equated with any specific, actual technique." Moreover, PTs can legally and ethically perform dry needling as part of a legal scope of practice pursuant to applicable educational and training requirements in accordance with state law.
    Posted by PT in Motion Editorial Staff on 6/2/2017 9:43:45 AM

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