1. The Turnbow Butterfly Therapeutic Tools
Steve Sapoznik, PT, DPT, CMTPT, ATC
The benefitsof manual therapydeliveredbyalicensedphysical therapistare welldocumented
for a varietyof conditionsincludinglow back,cervical,andshoulderpainsyndromes.1,2,4,6
When
manual therapyiscombinedwithexercise,the resultsare evenmore powerful andpositive
functional and measureable objective changeshave beendocumentedtooccur.2,3,4
In today'sever-changinghealthcare environment,whichincludeshighercopays,higher
deductibles,limitingaccess/visitstophysical therapists,andmax dollaramounts,itisessential
that individualshave the toolsandeducationneededtosafely andeffectivelyprovide care for
themselves.Educationanddischarge planningwithanindividualizedself-care programare some
of the essential rolesof aphysical therapistthatare initiatedatanindividual’sfirstvisit.
As brieflydiscussedabove,the effectsof manual therapycanbe powerful.Manual therapyplays
an integral role duringaphysical therapysession.The manual aspectof care is oftenwhata
patientvaluesinseeking physical therapy servicesandcan be directly correlatedwith their
satisfactionlevels duringphysicaltherapy visits. Asmostindividualsdonotsee a physical
therapistmore than2-3 timesperweek,use of aneffectiveDMEcan significantlyaugmentwhat
the physical therapististryingtoaccomplishintermsof decreasingpain,improving
function/mobility,andreturningthe individual backtowardtheirpreviouslevel orimproved
level of function. Byincorporatingthe TurnbowButterflyintointerventionandeventually
issuingthe tool tothe patient whenappropriate,thiscanall be achieved, whiledecreasingcosts
to the individual,byempoweringthe individual and givingthemthe abilityto have a‘manual’
componentintotheirhome exercise program.5
Detailedbelowismypatientselection,implementation,andoutcomesassociatedw/combining
relativelystandardphysical therapyw/instrumentassistedsofttissue mobilizationviathe
Turnbow Butterfly.I certifythat I personallyandsuccessfullyutilizedthe TurnbowButterfly
tool inthe outpatientclinical settingduringthe monthsof June-August2014 andbelow are 2
examples.
Patientscenario1:
History:56 y.o.female w/4 weekhistoryof calf andheel painthatis graduallyworsening.
Presentedtoclinicwith -5degreesof active dorsiflexion onaffectedLEand manyactive trigger
pointspresentthroughmedial gastrocnemius/soleusmuscle complex.Additionallypointtender
alongmedial calcaneal tubercleandherconditionisnegativelyaffecting prolongedstandingand
walkingbothrecreationally andatwork.Visual AnalogPainScales(VAS) were6-7/10when
aggravatedby prolongedwalkingandstanding.

2. Treatment:consistedof moistheattoposteriorknee andcalf,followedby10+ minutesof
manual deeptissue mobilizationtomedial gastroc/soleus,whichthenwasproceededby
prolongedgastroc/soleusstretchingandbalance andproprioceptiveexercisesof LE.
Results:Visits1-2manual therapyinterventionwasdeliveredbytherapist'sownhandshowever
patientthoughtitwas"too intense andpainful".Visits3-6beganusingthe Turnbow Butterflyto
same area and patienttoleratedmuchbetterandforincreasedtime. Able tocompletemore
exercisesfollowingmanual interventiondue toincreasedcomfortof the manual therapyviathe
Turnbow Butterfly.Physiologicallydid see flushingof the skinandimprovedsofttissue mobility.
Whenobjectivelymeasured,patient's active dorsiflexion improvedfrom-5degreesat
evaluationandto +5 degreeswhichis 10 degree improvement.She noted beingable to
ambulate relativelypainfree duringcommunityandrecreationalactivitiesandisoverall very
pleasedwithresults. VASscoresimprovedto1-2/10.
PatientScenario2:
History:74 y.o.male w/30+ yearhistoryof chronic low back pain(LBP).Overthe years,painhas
beensointense thathe has hadto be hospitalized.Hashadx-rayswhich showed"arthritis"per
patientreport. He was referredto byhisprimarycare physician.Onthe date of evaluation,he
noteda sharp increase orexacerbationof hisLBP while he wasseatedatwork.He isan
online care salesmansoprolongedsittingandworkingata computerisrequiredforhis job.
Patientwasobese howeverambulatoryw/outanyassistive devices.He deniedanymedical red
flagsat evaluation,includingnohx of cancer and nobowel andbladderchanges.
Examination:patient'sLBP wasveryhighand irritable ondate of evaluation. Hispaininlower
lumbarregionandlateral glute regionbilaterallywasdirectlyexacerbatedbyanyextension
posturesincludinglyingflat,transitioningfromsittostandingpostures,andbyupright
ambulation.He demonstratedaslightlykyphotic posture andveryshortstep/stride length
(almostshuffled) duringambulation.Hislumbarflexion measurementwas80 degreesand
lumbarextensionwas5 degrees(bothwithpain) duringexam.He had2+/5 lowerabdominal
strengthwhichwaspoor andverylimitedhamstring/hipmobility toPROMtestingbilaterally.
Treatment:myinitial thoughtfortreatmentwastodecrease the patient's immediateLBP and
irritabilitytoanymovement.Therefore,moistheat+softtissue mobilizationwasinitiatedat
beginningof patient'ssessions.Since the patientwasalarge man,I decidedtouse instrument
assistedsofttissue mobilizationviathe TurnbowButterflyto the patient's Bthoracolumbar
paraspinalsandQL region,aswell asboth IT Bandsall in side lyingpositions.Instrumentassisted
softtissue mobilizationwas administered for10-15 minutesandpositiveflushingof the skinwas
observable andInoteda relaxationof the tone andspasmsinlumbarregion.Lumbar
stabilization,hamstringstretching,andothergentle lumbopelvicstabilizationexerciseswere
slowlyimplementedover9visits.
Results:Onthe date of the patient's 9th visitwhichwas~4 weekslater,aformal re-evaluation

3. was performed.The patienthadseenasignificantincreaseintolerance toexercise andabilityto
ambulate comfortablyperage expectednorms.He washavinglessLBP while seatedatwork
and demonstratedabilitytocompletehisshiftsw/outtakinganyformof painmeds or mm
relaxers.He notednearlyfull resolutionof hisBglute medpaininlateral hipregionbutstill had
some mildtomod LBP inthe thoracolumbarregion.Hislumbarflexion improvedby5-10
degreesandlumbarextensionimprovedby5 degreesaswell withmuchlesspainduring
repeatedmovementsof both.Physical therapy wasrecommendedtobe continuedforanother
2-4 weeksaswe were makingfunctionalandobjectiveprogresshoweveratthispointI moved
to Indianaandanothertherapisttookoverhisplanof care.
Takeaway:the use of instrumentedassistedsofttissue mobilizationinthoracolumbarandhip
region+ the additionof targetedandspecificstabilizationexercises waspromotingareturn
towardhispreviouslevelof functionwhichwascommunityambulationandabilitytositfor
prolongedperiodsatworkwithout use of painmeds orsignificantrisesinLBP.Givenhis30+
yearhistoryof LBP, a majorgoal for thispatientwasto be able to complete averyspecificand
flexion biasedhome exercise programasthese exercisesprovedtobe beneficial. Additionally,as
softtissue mobilizationormanual therapywaseffective indecreasinghisLBP,he wouldhave
benefitedfromthe abilitytoprovide some formof thisinterventionhimself.Thisisexactly
where issuingthe TurnbowButterflywouldhave appropriate.
The Turnbow Butterflycan be utilized,andthe time aphysical therapistusesitfor,billedforby
2 differentCPTcodes. The codesare: TherapeuticExercises(97110) and Manual Therapy
(97140). A case can be made that othercommonCPT codescan be billed dependingonthe
physical therapistsintentof treatment(i.e.TherapeuticActivityand/orNeuromuscular
Reeducation).
In the outpatientsetting,DMEcan be distributedin2ways:1) the therapistrecommendsatool
or device andthe patientpurchaseswiththeirownmoneyorwithFSA/HSA accountsand2)
insurancesmaycoverthe costs of DME, dependingonthe plan,if aphysicianscriptissubmitted
and the DME isdeterminedmedicallynecessary.A physical therapistgenerallyisthe one to
suggestuse of DME can justify medical necessitywithinanindividual’splanof care. This
scenarioislargelythe same whetherdiscussingprivate insurance orworkmen’scompensation
benefits.
Personallyspeaking,there isnotasingle weekthatgoesbyinwhichI am not issuingsome form
of DME to the patient,regardless of cost.Consumerswillpayforservicesanddevicesor
equipmenttheyseethe value in. A well-designedandindividualizedhome exercise programcan
have a tremendousimpactonan individual’sshortandlong-termhealthandthe
Turnbow Butterfly wouldbe a valuable additiontoboththe physical therapyclinicand home
for individual use.
*“A proactive approachto preventionandmaintenance providesacompetitiveadvantage,
the Turnbow Butterflyis the perfectself treatmenttool forathletestostayinthe game.”
*“The use of the Turnbow Butterflycan increase rate of recoveryandreduce re admissions.”

4. 1. Bang MD, et al. Comparison of SupervisedPhysical Therapy
Withand Without Manual Physical Therapy for Patients
with ShoulderImpingementSyndrome. JOrthop Sports Phys
Ther. 2000;30:126-137.
2. Bronfort G,Evans R, AndersonAV, et al. Spinal manipulation,
medication,or home exercise withadvice for acute and sub
acute neck pain: a randomizedtrial. Ann. Intern. Med.
2012;156(1 Pt 1):1–10.
3. WalkerMJ, BoylesRE, Young BA, et al. The effectivenessof
manual physical therapy and exercise formechanical neck
pain: a randomizedclinical trial. Spine.2008;33(22):2371–
2378.
4. Hoving JL, de Vet HCW,Koes BW,et al. Manual therapy,
physical therapy, or continuedcare by the general
practitioner for patientswith neck pain:long-termresults
from a pragmatic randomizedclinical trial. Clin J Pain.
2006;22(4):370– 377.
5. Korthals-de Bos IBC, Hoving JL, van Tulder MW,et al. Cost
effectivenessofphysiotherapy,manual therapy, and general
practitioner care for neck pain: economicevaluation
alongside a randomizedcontrolledtrial. BMJ.
2003;326(7395):911.
6. ClelandJA,Fritz JM, KuligK, etal. Comparison of the
effectivenessofthree manual physical therapy techniquesin
a subgroupof patientswith low back pain who satisfya
clinical predictionrule:a randomizedclinical trial. Spine.
2009;34(25):2270-2729.
Author:
Steve Sapoznik, PT, DPT, CMTPT, ATC
Facility Manager/Physical Therapist/Athletic Trainer
Athletico Physical Therapy
Bloomington, IN Clinic
3243 W. 3rd Street, Bloomington, IN 47404
P: 812-668-1880 | F: 812-668-1881
steven.sapoznik@athletico.com | ssapoznik@athletico.com )