"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, January 25, 2009

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.
"I just can't go on like this", she said.
Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

  1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"

  2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:
"...depression is rapidly becoming the second leading cause of disability in the world."
Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:
  • sitting
  • studying
  • sleeping
...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

 ICF descriptorICF code
Body Functions
Pain in Head and Neckb28010
 Regulation of Emotionb1521
 Psychomotor control (agitation)b1470
Activities & Participation 
Maintaining a lying positiond4150
Maintaining a sitting positiond4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.

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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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