We are excited to announce that Chicago, IL is the site of the IM Professional Conference 2007! See the details below:

12

REGISTER TODAY!
*You do not have to be an IM Provider to attend
 

Learn the answers to Frequently Asked Clinical Questions

You can also e-mail us your clinical questions at clinicaled@interactivemetronome.com
 

How to make decisions on the first day of IM with your patients
 

ANSWER: Please see the Decision-Making Steps to Get Started with IM.

Do pre-LFA: observe performance.

What to look for:

Is the patient able to motor plan/sequence? If any problems, you will see movements that are choppy, stilted, groping, poorly sequenced (esp. with feet), ballistic (hitting very hard with hands), linear instead of circular, and timing will be random (usually with MS task average bouncing back and forth between very early and very late) and patient may have hard time keeping up with beat of 54 (it may appear to be too fast for them).

Are movements uncoordinated for other reasons? Ataxia, hemiparesis, etc. You will see timing varies greatly and patient will have a hard time keeping up with the beat (at tempo 54).

Does patient hit very early most of the time (> 200 ms)? This indicates problem with impulse-control and executive functions.

Does patient hit very late most of the time (>200 ms)? This indicates problem with cognitive and/or auditory processing - processing speed is delayed. Patient will seem to have trouble keeping up with the beat.

Does the patient get distracted or perform worse on the last task of LFA (B Hands with Guide Sounds) as compared to the other LFA tasks, in particular task 1, B Hands? If so, this suggests difficulty with auditory processing and selective attention. If the patient performed well (within normal range on all LFA tasks) except for the last task with guide sounds, this patient is still a candidate for IM to improve processing skills. Keep in mind that all of the LFA tasks (except for the last one) are with the ref tone alone and are very short (30 sec to 1 min in duration)...not long enough to capture deficits in sustained attention and no distractions to capture ability to filter distractions or process auditory information in the presence of background 'noise.'

Does the patient hit in a manner that is chaotic, random, and unrelated to the reference tone - what is referred to as dissociative? This suggests severe impairment in attention and processing capabilities via the auditory modality (hearing IM via headphones). Timing scores will generally be >300 ms and random.

Does the patient continue to clap or tap even after the ref tone has ceased and the task is finished? This suggests severe impairment in attention and executive functions (perseveration).

Does the patient complain or otherwise appear to have difficulty with the volume of the reference tone and/or guide sounds during LFA? The patient may turn red, get flustered, verbalize discomfort, and/or performance may deteriorate over time during LFA. This suggests auditory, sensory, and/or cognitive processing deficits with auditory hypersensitivity.

Does the patient complain of or otherwise exhibit sensory defensiveness to the IM equipment (headphones, glove, feel of wires hitting their leg during tasks, your touch as you put the IM equipment on them? Timing may be off or may not be...may exhibit trouble focusing, lack of motivation toward task, or may exhibit behavioral outburst. This suggests sensory processing/integration problem.

• To start IM treatment, you always follow the Six Phases for each patient regardless of their deficits. It is patterned after a learning curve. Using hand tasks only (B Hands, R Hand, L Hand), patients repeat the same hand tasks over and over in each session until they learn what to do when they hear the ref tone (Phase One), then what the guide sounds mean and how to respond to them when they hear them (Phase Two), then achieve better rhythm and timing (Phase Three). Once they've achieved a frame of reference, (okay, this is what it feels like, this is how I should do it), then move on to foot, bilateral, and balance tasks (Phase IV), fine tuning motor planning and cognitive abilities for short tasks (Phase V), and finally, improving sustained attention and physical endurance (Phase VI).
• The goals of your first IM session (in Phase One) are the following:
• Recognize the beat is periodic & attempt to synchronize
• Work on basic focusing & sensory integration skills
• Work on coordinated, rhythmical movement
  Hand exercises (1 – 3)
  Short duration (up to 100-200 reps)
  Guide sounds off

Use your observations during LFA to guide you in the first IM treatment session (*Use hand tasks only in first treatment session.):

• Techniques can be combined for patients who exhibit several of the above deficits.
• Repeat the same hand tasks over and over until you get the IM settings just right from a motor, cognitive, and sensory standpoint and the patient appears to be trying to match the beat (even though scores are still poor) - the intensity and repetition are part of what makes IM so effective.
• IM is most effective if provided 2 - 3 times per week. There is always a pressing need to work on ADLs, self-care, basic attending, communication and language, behavior BEFORE IM....it is erroneous to hold off on doing IM until these goals are accomplished. By tapping into core functions of attention, processing, executive functions, and motor planning/sequencing, IM helps the patient accomplish these goals and others MUCH faster. If length of stay or insurance coverage/visits are limited, the best outcomes are obtained by using IM. Significant gains are seen within 2-4 weeks at 3x/week (varies from patient to patient). Some patients meet all of their rehab goals within 4-6 weeks with IM. More severely impaired patients require longer IM treatment (up to 60-90 days at 3x/week). They need to know that ADLs etc improve when doing IM even though they are not directly working on ADLs...this is the hardest part mentally for therapists to get over...and what causes many of them to stick with the familiar and not use IM.

Areas of improvement include:

Cognitive Skills
Initiation
Attention-shifting and mental flexibility (perseveration)
Sustained attention
Selective attention in background noise and other distractions
Cognitive stamina (fatigue)
Planning
Organization
Sequencing
Prioritization and time-management
Memory
Problem-solving and reasoning
Mathematics
Speed of mental operations

Language Skills
Auditory processing
Auditory comprehension
Word-finding
Reading comprehension and speed
Thought organization and communication effectiveness/efficiency

Behavioral Skills
Impulse-control/disinhibition
Control of aggression
Social aptitude
Self-esteem and self-confidence

Motor Skills
Balance & stability
Motor planning & sequencing
Coordination
Speed & agility
Endurance
Gait
Gross and fine motor use of prosthetic limbs
(upper and lower extremities)
Handwriting

Sensory Processing Skills
Sensory modulation
Sensory over-responsivity
Sensory under-responsivity
Sensory seeking
Sensory discrimination

ANSWER: When it comes to insurance authorization, getting authorization for IM services is no different from getting it for other services provided.  Don't ask for authorization for IM treatment...the insurance company will not recognize it as IM does not have its own CPT code for billing.  Rather, ask for authorization for "evaluation and treatment" for "ST", "OT", or "PT."  IM is simply a part of the comprehensive treatment approach.  The ST would bill either Speech-Language Therapy or Cognitive Development. The OT would bill Therapeutic Activities, Neuromuscular Reeducation, Cognitive/Perceptual Training, etc.  The PT would bill Gait Training, Neuromuscular Reeducation, Therapeutic Exercise, etc.  The number of visits authorized by insurance will be determined by the insurance plan, the treatment diagnosis, and how the therapist articulates the treatment approach and documents changes in function as a result of the interventions provided.  Getting additional visits authorized will depend upon the same.