"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, August 12, 2008

The Pragmatic Physical Therapist Avoids Models

I recommend the August 2008 Physical Therapy Journal for the Case Report titled
Process for Applying the International Classification of Functioning, Disability and Health Model to a Patient With Patellar Dislocation by Kevin Helgeson and A Russell Smith Jr

(subscription required)

I blogged about this article just two days ago

The patient was an active 23-year old female graduate student who wanted to return to hiking and running.

"She sustained the following... second-degree tear of the medial collateral ligament (MCL) of the right knee, with a lateral dislocation of the patella. She was referred for magnetic resonance imaging (MRI) of her right knee; the MRI was performed the following week. The MRI findings reported by the radiologist were “sprain of the medial collateral ligament with overlying edema and bone bruises of the posterior medial tibial plateau and of the lateral femoral condyle with a small knee joint effusion.”

What I found helpful was Helgeson and Smith's pragmatic approach to decision-making.

"The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was reevaluated through an assessment of the level of improvement of the patient’s primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

By pragmatic I mean the ability to change the plan of care based on the patient's response, measured at the level of the functional ability - in this case walking, hiking and squatting.

This pragmatic approach avoids the use of models - simplifications of human structure and function that are used as aids to decision-making.

The pragmatic approach relies on test data, functional ability, to make decisions.

I would have used the OPTIMAL test to measure functional ability.

The problem, as I see it, is that the use of test data to make decisions 'pigeonholes' physical therapists - that is, it forces them to make decisions that might be contrary to their favorite model or treatment technique.

Full disclosure: My favorite treatment technique for lower back pain is spinal stabilization.

When stabilization doesn't work, as indicated by my OPTIMAL score, I am forced to resort to other means, such as ultrasound or massage to treat the patient.

I don't like it - but I do it.

I wonder if other physical therapists are similarly vexed by using data?

Or, do you just stick with the model?

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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 .

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