"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 14, 2008

When is a physical therapy diagnosis not a physical therapy diagnosis?

The most recent issue of The Orthopaedic Section's Physical Therapy Practice contains Developing a Physical Therapy Diagnosis for a Patient with Upper-extremity Paresthesia: A Resident's Case Problem by Trevor Lentz, Marty Huegel and Mark Bishop.

The authors state...
"the most likely source of the symptoms was cervical radiculopathy".
The problem is this 'physical therapy diagnosis' of cervical radiculopathy is that it is a medical diagnosis.

Medical doctors can get a little upset when they hear about physical therapists making medical diagnoses.

We can do better.

Instead, why not a functional diagnosis? Why not a physical therapy diagnosis that conforms to the International Classification of Functioning, Disability and Health (ICF) framework?

Using the ICF framework, measure activity limitations and impairments in body structure and function. Link activity limitations to impairments with the physical therapy diagnosis.

According to the article, the patient's symptoms "were limiting his sleep and work tolerance". These are the self-reported activity limitations.

The measured impairments included the following:
  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test
  • positive Upper Limb Tension Tests (A&B)
  • limited cervical rotation bilateral
Why not a physical therapy diagnosis that simply states that the activity limitations were caused by the measured impairments?

"Limited sleep and work tolerance caused by
  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test
  • positive Upper Limb Tension Tests (A&B)
  • limited cervical rotation bilateral
Why do we need a label?

The APTA House of Delegates policy statement on physical therapist diagnosis states...
"The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client."

Especially, why do we need a medical label that does not inform decision-making for physical therapists?

Ivory Tower Statistics

Here's the part where I'll get myself into trouble.

The authors diagnosed this patient based on a larger positive change in post-test probability for cervical radiculopathy than for carpal tunnel syndrome or thoracic outlet syndrome.

Yet when I read the 'exercise flow sheet' I find no treatments that would apply to a 'diagnosis' of cervical radiculopathy that might not also apply to a 'diagnosis' of Thoracic Outlet Syndrome.

So, what's the point?

Why encourage physical therapists to learn and study powerful statistics (likelihood ratios and nomograms) that don't direct daily clinical decision-making?

Use the list of findings to inform the decision-making process of what to include in the plan of care.

Assuming I measured the same impairments on the same patient couldn't I take the list of findings and design a plan of care that lead to the same exercise flow sheet?

  • asymmetric grip strength
  • sensory loss in the C6 dermatome
  • positive Neck Distraction Test - Manual Cervical Distraction
  • positive Upper Limb Tension Tests (A&B)- Cervical Stretches
  • limited cervical rotation bilateral - AROM
There, I didn't have to use any statistics to make a similar plan of care from the same list of findings.

Instead of making Physical Therapy Diagnosis more complicated, let's make it easier.

Unfortunately, the aforementioned HOD policy statement does not encourage improving the process. Instead, it sticks with outdated labels...

"In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals."

Emphasize the process, not the label.

Disability does not need a medical diagnosis label.

Disability defies labels because people are more complicated, and more interesting, than pathology.

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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"

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