"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

Sunday, September 21, 2008

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:
  • Body Functions
  • Body Structures
  • Activity and Participation
  • Environmental Factors
...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...
"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:
  1. Stiff upper cervical sidebending (C0-C2).

  2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).

  3. Decreased cervical rotation ROM, bilateral.
...to be treated with the following...
  1. Therapeutic Exercise (97110) for endurance of DCF muscles.
  2. Manual therapy (97140) for ROM, PROM, massage.
  3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
  4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."
The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:
  • Mobility of several joints (b7101)
  • Endurance of isolated muscles (b7400)
Body Structure
  • Ligaments and Fasciae of the Head and Neck (s7105)
  • Bending (d4105)
  • Sitting (d4103)
  • Pushing (d4451)
Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

  • the patient
  • the physician
  • my physical therapist and physical therapist assistant peers
  • third party payers
  • federal policymakers
  • national and international health researchers
  • rehabilitation professionals from related professions
  • the man on the street (?)
If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.


  1. Vibrant health is not just the absence of disease; it's a joyfulness that should be inside us all the time. It's a state of positive wellbeing which is not only physical but emotional, psychological and ultimately even spiritual.

  2. Well put.

    Health is a complex concept that, nevertheless, can be studied and measured.

    The International Classification of Function, Disability and Health has descriptors for different aspects of health, specifically emotional health.

    Some of the descriptors include the following:

    b1520 Appropriateness of Emotion
    b1521 Regulation of Emotion
    b1522 Range of Emotion
    b1266 Confidence

    Additionally, the Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Orthopaedic Section of the American Physical Therapy Association identify risk factors that may lead to the development of neck pain.

    These risk factors include the following:

    history of neck and shoulder symptoms
    more worrying
    worse perceived health
    a moderate or bad quality of life

    Note that some of these risk factors closely parallel the descriptors in the ICF model.

    Note that 'b1266 Confidence' can be measured using the confidence portion of the OPTIMAL scale.

    Thank you for your comment.



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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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