"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

Saturday, February 9, 2008

The Orthopedic Surgeon Test

The Orthopedic Surgeon Test is a tongue-in-cheek name for a pragmatic approach to physical therapy clinical decision-making.

Whenever a physical therapist makes a clinical decision the test is to ask yourself the following question:

"What would the orthopedic surgeon think about this decision?"

So, if the physical therapist is asked a common clinical question like, for instance, the following:

"Do I put heat or ice on this hot, red, swollen and tender body part?"

Then, when you make the clinical decision to advise the patient to put ice on their inflamed body part you would certainly pass the Orthopedic Surgeon Test.

Physical therapists should extend this level of critical scrutiny to every clinical decision.

Perhaps I put too much pressure on or give too much credit to orthopedic surgeons in naming this test for them.

My assumption is that since their decisions ultimately direct the care for many of our orthopedic patients then they should get the glory (or the blame).

Orthopedic surgeons commonly base their decisions on independent measurements like x-rays. I use the term independent rather than 'objective'. Independent measurements imply that their interpretation will be the same for every observer.

Any decision that is based on a measurement will withstand scrutiny.

Physical therapists should also base their decisions on measurements.

Measurement eliminates argument.

A good example of clinical decision-making happened yesterday in the clinic. A patient asked me for a stretching exercise for her left hamstring - she said it was 'tight'.

This patient had a two-year old L4-5 microdiscectomy, complete motor palsy of the Flexor Hallucis and Digitorum Longii muscles (S1), sensory loss along the entire S1 dermatome and hamstring weakness (S1).

Additionally, her supine Straight Leg Raise (SLR) test measurements were the folowing:

Left 88 degrees
Right 85 degrees.

The video demonstration of this measurement technique can be found here.

Her left hamstring was longer than the right.

Perhaps because the hamstring muscle was weak she percieved 'tightness' and felt the urge to stretch.

Measurement, however, revealed that the hamstring was not 'tight'. The hamstring was not short and did not need stretching.

I re-measured the SLR and explained my findings to the patient. I advised her against stretching the hamstring muscle.

This young lady has a physical therapy plan of care that emphasizes stabilization training and avoidance of endrange movements like flexion and extension. Her understanding of physical therapy had led her to believe that stretching was a part of every patient treatment and thus would be a part of her treatment.

In fact, the measurements revealed that her mobility charcteristics could be labeled 'hypermobility' and her clinical presentation (which is more detailed than I have presented here) could be labeled as 'lumbar instability'.

Stretching, for this young lady, could be hazardous.

Based on my measurements I was comfortable in standing my ground and recommending against the patients stated desires. I did not provide her with the treatment that she thought she wanted.

If the orthopedic surgeon called and asked for hamstring stretching I believe I would make the same recommendations.

My clinical decision passed the Orthopedic Surgeon Test.

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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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