"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 18, 2009

Is the OPTIMAL a subjective scale?

"It's a hurt but not a pain."

"My pain hurts when I stand at the counter to fix meals longer than five minutes."

"It gnaws and hurts and then I get angry because I can't do anything anymore!"

Physical therapists work with these folks every day.

You hear this every day.

Me, too.

Outpatient physical therapists working for Medicare are asked to quantify pain and activity limitation using baseline activity scales, such as the following:These scales, however, have typically been labeled as 'subjective' measures of patient function because patient self-report is not as reliable as a clinician's assessment.

Reliability is exactly the point when you see a side-by-side comparison of several traditional measures of patient illness and function.

Richard Deyo, MD originally presented data that I have reproduced here in this chart:

Reliability of Potential Outcome Measures for Back pain Trials
TypeMeasureEstimated reproducibility (test-retest correlations)
LaboratorySpinal fluid endorphins
Paraspinal EMG activity
Physical MeasurementsAnterior spine flexion0.50
Passive straight leg raise0.78
Ankle dorsiflexion strength (dynamometer)0.50
Function & symptoms'Ability statements'0.90
Pain (VAS)0.94

The reliability of the OPTIMAL scale is determined by a different method - a method more appropriate for studying difficulty or confidence. (Guccione et al)

OPTIMAL reliability
OPTIMAL0.85 to 0.95

Note that the OPTIMAL is more objective than typical measures of physical function - the ones you and I learned in PT school.

Can we do better?


As we've noted elsewhere on this blog, the OPTIMAL is a political and a policy compromise - not an academic or a clinical superstar.

But, in my opinion, using the OPTIMAL facilitates an improvement in physical therapists clinical decisions and, perhaps, the notes we write.

Since 60% of physical therapists probably don't use baseline outcome measures (Copeland, PTJ Dec. 2008) the OPTIMAL represents a 100% improvement.

The Medicare Minimum Documentation Requirements (Transmittal 88) states...
"If results of one of the ...instruments (OPTIMAL, FOTO, AM-PAC) above is not recorded, the record shall contain instead the following information..."
  1. Identification of other health services concurrently being provided for this condition (e.g., physician, PT, OT, SLP, chiropractic, nurse, respiratory therapy, social services, psychology, nutritional/dietetic services, radiation therapy, chemotherapy, etc.), and/ or

  2. Identification of durable medical equipment needed for this condition, and/or

  3. Identification of the number of medications the beneficiary is talking (and type if known); and/or

  4. If complicating factors (complexities) affect treatment, describe why or how. For example: Cardiac dysrhythmia is not a condition for which a therapist would directly treat a patient, but in some patients such dysrhythmias may so directly and significantly affect the pace of progress in treatment for other conditions as to require an exception to caps for necessary services. Documentation should indicate how the progress was affected by the complexity. Or, the severity of the patient’s condition as reported on a functional measurement tool may be so great as to suggest extended treatment is anticipated; and/or

  5. Generalized or multiple conditions. The beneficiary has, in addition to the primary condition being treated, another disease or condition being treated, or generalized musculoskeletal conditions, or conditions affecting multiple sites and these conditions will directly and significantly impact the rate of recovery; and/or.

  6. Mental or cognitive disorder. The beneficiary has a mental or cognitive disorder in addition to the condition being treated that will directly and significantly impact the rate of recovery; and/or.

  7. Identification of factors that impact severity including e.g., age, time since onset, cause of the condition, stability of symptoms, how typical/atypical are the symptoms of the diagnosed condition, availability of an intervention/treatment known to be effective, predictability of progress.
Yes, OPTIMAL measures a subjective experience...

"My leg hurts - it burns to the ankle and I can't walk!"

But OPTIMAL is an objective measure of a subjective experience - and it's helped me help my patients more.

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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.
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