"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Tuesday, October 23, 2007

Who Needs Physical Therapy Diagnosis? (Part 1)

The Physical Therapy Diagnosis
Who needs physical therapy diagnosis?
Who, beside the physical therapist and the patient, needs a physical therapy diagnosis?
The doctor needs the physical therapy diagnosis from the physical therapist.

Physical therapy diagnosis helps the doctor.

The physical therapy diagnosis helps the doctor because the diagnosis is stated in universally understood terms (eg: range-of-motion and strength). The physical therapy diagnosis avoids medical diagnosis (eg: tendonitis) and so the physician is not threatened or offended.

Diagnosis systems which invent specific terms to describe commonly encountered clinical phenomenon are too complex for the busy physician or the distracted patient to try to learn.

Physical therapy diagnosis helps the new graduate physical therapist.

Simple physical therapy diagnoses (eg: shortened hamstring muscle) encourage new graduates and those older graduates who may not have taken advanced orthopedic physical therapy coursework to make their initial diagnosis.

As the new graduate begins to gain confidence in their diagnostic skills they will naturally progress to recognized patterns of impairments that tend to occur together. This pattern recognition will make the diagnostic process faster and easier.

Automate the decision process

Making a physical therapy diagnosis at the initial evaluation improves the decision-making process by automating the goal setting and the choice of interventions. Diagnostic decisions flow automatically from a limited number of options that apply to measured impairments, for example: a shortened hamstring muscle can be treated with the following interventions:

  1. Manual Therapy (97140), massage or myofascial release.
  2. Therapeutic Exercise (97110): passive or active range-of-motion, stretching exercises or progressive resistance exercise.
  3. Neuromuscular Reeducation (97112) to lengthen the hamstring with a stable lumbar spine.

The goal would flow directly from the measurements. For instance, if the right hamstring has 70 degrees straight leg raise and the left hamstring has 90 degrees straight leg raise then the goal would be written as follows:

Increase right hamstring straight leg raise from 70 to 90 degrees.

Another Example.

For example, a patient comes in with heel pain.

You measure the fastest, easiest metric for the foot: Standing Heel Raise. You obtain the following values:

Standing Heel Raise: 6cm Right
10cm Left

Standing heel raise is a standardized measurement that purports to describe the strength of the posterior leg muscles and the range of motion of the ankle joint.

Our measurement indicates that the posterior leg is weak. The initial goal of therapy should be to strengthen the weak muscle.

The physical therapist would set the first long term goal of therapy as follows:

Strengthen the right Standing Calf Raise from 6cm to 10cm.

Cut Scores

Ten centimeters is the ‘cut score’ that defines a treatment success or a treatment failure. Cut scores can be determined empirically or statistically (See Risk and Physical Therapy by Newman and Allison).

The physical therapist selects the appropriate intervention to meet the long-term goal. In this example, therapeutic exercise is the most appropriate intervention for calf strengthening.

The documented description of the intervention would read as follows:

“Therapeutic exercise for strengthening the right calf muscle.”

The description of the intervention would need to be noted in the plan of care but not in each subsequent note (see Medicare Benefit Policy Manual Transmittal 63).

The diagnosis is predicated on good measurement. With good measurement and good diagnosis the physical therapist can do the following:

  1. Set goals
  2. Select interventions
  3. Determine progress by periodic re-assessments
  4. Make predictions about the future
  5. Give a discharge diagnosis

Automating the decision process with good measurement and good diagnosis allows the physical therapist to personally step back from the patient outcome. The physical therapist can identify and measure the impairment and link the impairment to the functional limitation.

The process of selecting the interventions that will best address the impairments and the functional limitations becomes a negotiated interaction between the physical therapist and the patient.

Physical therapy diagnosis de-emphasizes the importance of modalities. I’ve never seen a muscle get stronger with ultrasound.

A Final Example

Another example should help make my point.

My last patient this morning had the following diagnoses:

  1. Weak bilateral hip internal and external rotator muscles
  2. Weak bilateral hip abductors
  3. Weak left hip flexor muscle
  4. Short left hamstring muscle
  5. Stiff bilateral trunk rotation range-of-motion

I made these diagnoses with precise measurements. I compared the measurements to a ‘cut score’ from a large sample of patients. Any value that failed to reach the cut score for range-of-motion or strength was ‘weak’ or ‘stiff’ or ‘short’.

The point is that this patient had many physical impairments. Obviously she also had profound disabilities and severe pain. No amount of ultrasounds or hot packs will ever improve these impairments.

A physical therapy plan of care that is built around modalities will undermine the urgency of improving the true cause of the pain and the disablement: impairments in strength and range-of-motion.

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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

"Make Decisions like Doctors"

Copyright 2007-2010 by Tim Richardson, PT.
No reproduction without authorization.

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