"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

Monday, April 27, 2009

When should you use the OPTIMAL Scale?

The Case of Mr. Spooner

Some readers of this blog have posited that you should never, ever use the OPTIMAL scale because it is "crap" and not a useful tool for clinical decision-making.

The shortcomimgs of the OPTIMAL have been previously discussed here and are well-known.

OPTIMAL is a 'setting-specific' tool for activity limitations affecting the upper body, lower body and trunk.

That is, OPTIMAL is appropriate for patients who can ambulate into your clinic, irrespective of wheter their conditions affect their knees, hips, spine, shoulder, etc.

OPTIMAL might not be appropriate for patients in acute care or in long term care.

The Case of Mr. Spooner

The reason I bring this up is because Mr. Spooner (see above) came into my clinic today.

Mr. Spooner had the following physician's diagnoses:
  1. Gait Disorder
  2. Post-op lumbar laminectomy
  3. Cervical herniated disc
  4. Leg weakness
Normally, for these diagnoses, I would, provisionally - based upon the findings, decide to use these outcome scales, respectively:
  1. Modified Falls Efficacy Scale
  2. Oswestry Scale
  3. Neck Disability Index
  4. Lower Extremity Functional Scale
These outcome measures are "condition specific" - that is, the physical therapist chooses the scale based on how well she feels the scale reflects the activity limitations discovered in the initial evaluation.

Widespread Panic

But, poor Mr. Spooner - he was a mess!

I didn't want to have him fill out four separate pages of data. He just wanted to feel better - not write a book!

Fortunately, our clinic has been using the OPTIMAL scale for almost three years - we have only recently started using the condition-specific measures for single-diagnosis cases.

Mr. Spooner was done with his questionnaire in 3-4 minutes and on his way.

We had valid, reliable data for use as an outcomes baseline. If, at some point, one of his conditions becomes more acute or refractory to treatment we may ask him to fill out one of the condition-specific measures.

Is OPTIMAL a last resort?

Better than a last resort OPTIMAL is a tool for clinical decision-making.

Not the best tool you have - and certainly not the worst.

Like any craftsman, you may choose to use your tools to gain the best patient outcomes you can.

You decide.

Tuesday, April 21, 2009

Should orthopedic physical therapists always test for nerve root injuries?

Should physical therapists complete a full neurological screening for every patient with lower back pain?

Over 12 years ago, Richard Deyo, MD, MPH asked the question...
"Should the physician complete a full neurological examination of every patient - even those who present with no leg pain?"
I almost always believe that, as specialists, physical therapists should 'step up to the plate' and screen for undiagnosed pathology that primary care physicians may not find.

Falls risk is one example.

Red flags for spinal pathology are another.

The Case of Mrs. Rose

I recently saw Mrs. Rose for falls prevention - she presented on a four-point walker, too tired to stand and at serious risk for falls.

Her tests and measures were as follows:

Mrs. Rose's ScoreExpected Normal
Modified Falls Efficacy Scale62%
Timed Up and Go Test25 sec.11.5 sec.
Functional Reach Test12cm25.1 sec.
Balance and Reach Test22cm
Single Leg Stance Time2 sec.11.3 sec.
Ten-times Chair Squat Testunable
Quadriceps Strength?Normal

Based on her performance scores, she was at high risk for falls, she was a terrific candidate for physical therapy for falls prevention and she seemed to really need our help!

The current trend in government health care policy and in the professional literature is focused on recognizing patients at high risk for falls.

So, since she presents as a high-risk falls patient - should I have also tested for nerve root pathology?

If the omission is unintended, that is, if the physical therapist does routinely screen for nerve root injuries, and in one case fails to do so then my error may be an 'anchoring error'.

Jerome Groopman, MD (How Doctors Think) describes anchoring errors in medicine as seizing upon the first available diagnosis when seeing the patient.

Hindsight is 20/20

Well, as it turns out she has a L3 nerve root palsy causing quadriceps atrophy, difficulty with weight acceptance during stance and episodes of knee buckling during standing.

I discovered the pathology and subsequent impairments on her third visit.

Impairments matter

The current 'focus on function' that has resulted from our professional literature and the government's policy emphasis has left many physical therapists (myself included) with the impression that impairments aren't important in the classification of function.

Let my mistakes be a lesson - physical therapists should keep screening for nerve root pathology and their resulting impairments.

Monday, April 20, 2009

Why 'Quality' Care is Inevitable

In "Why 'Quality' Care is Dangerous" Jerome Groopman, MD complains the definition of 'quality' is too narrow, eg: only 'quality' that conforms to consensus standards set by Medicare experts is of sufficient 'quality'.

Consensus means measurement of simple clinical procedures that fail to capture the complexity of medical decision-making, such as diabetic management.

But 'quality' in P4P is meant to capture under-treated aspects of big, high-cost drivers in medicine, like why do so many people suffer from lower back pain (LBP)?

For example, pain is the number one reason people go to see a doctor. A simple zero-to-ten pain scale is more sensitive to clinical change than a comprehensive pain questionnaire yet pain is assessed in less than 50% of the clinical encounters in America.


One P4P quality metric for physical therapists is pain assessment and implementing a plan of care to treat pain.

Lower back pain has passed cancer spending in research dollars and, prior to 2006, small-dollar, high-volume CPT codes for therapeutic spine treatments were growing at over 35% per year.

Another simple problem in medicine:

Why are so many Americans obese?

Obesity, not disease, is the primary driver of disability in America.

Another quality metric for physical therapists is assessment of body mass index.

While Dr. Groopman could, no doubt, cite examples of complexity in medical decision-making involving LBP and obesity the vast majority of these cases are simple diagnoses that relate to lifestyle factors, not exotic diseases.

There's that old saw in medicine: "When you hear hoof beats, think horses - not zebras"

Show Me the Money!

The biggest, costliest health problems in America are not rare diagnoses - the costliest problems are the result of daily choices we make about diet and exercise.

Dr. Groopman is right, P4P simplifies the collection of basic data which may interfere with complex physician and physical therapist decision-making.

But, it's not the complex decisions American doctors needs help with...

We need help with the simple decisions.

Friday, April 17, 2009

The 'Old School' case for impairments

Call me 'old school'... (some folks have called me that, and more).

I still treat some impairments - it's how I was trained.

There is a certain amount of satisfaction in measuring a stiff joint, fixing it with my 'old school' physical therapy techniques and getting the patient better.

It makes sense.

Today, however, physical therapists measure patient characteristics that predict the treatment the patient should get.

We don't measure as many impairments anymore. Some of the measurement are not even 'physical' - now we measure 'fear of movement'.

These new measurements are better because they are predictive of the patient's ultimate outcome whereas impairments (eg: ROM, strength, etc.) generally aren't predictive of outcomes.

The new way makes sense, too.

Teaching an Old DogWell, this 'old dog' can still learn some new tricks, like...None of these concepts were taught in PT school in 1992 and, ironically, they weren't taught in any of my 'old school' continuing education courses at 'Marriott U.'

The New School

A new article in April's JOSPT shows, however, that some impairments are still worth measuring - BECAUSE they may be predictive of the patient's ultimate outcome.

Lentz, Barabas, Day, Bishop and George showed that the flexion ROM variable was the strongest contributor to shoulder function in a model that included variables such as...
  • duration of symptoms
  • sex
  • age
  • mechanism of injury
  • average pain intensity
  • flexion ROM
  • Tampa Scale of Kinesiophobia
So, my 'old school' training may still be useful after all!

The Outcomes

While shoulder flexion ROM was the strongest contributor to shoulder (dys)function
"...the immediate clinical relevance of these findings was unclear."
In other words, does improving shoulder flexion ROM with my 'old school' PT techniques (stretching, joint mobs, manipulation, cranio-sacral (not), whatever...) lead to better outcomes?

Physical therapists are still looking for the most parsimonious measurements that will predict outcomes for patients.

Are impairments still on the list?

Wednesday, April 15, 2009

X-prize for physical therapy: $10 million for autonomous practice

The X Prize foundation announced yesterday the creation of a $10 million prize for a "bold, measurable and scientific" proposal that "results in viable, creative and achievable health care system changes."

Physical Therapists Take Note

This is your skill set!

The winning proposal will "improve care within communities and proactively assist individuals in optimizing their health in a way that reduces overall costs."

How to measure health?

Health can be measured differently: some measures are better than others.

For instance, rate of post-surgical bony fusion would not properly reflect the primary desired outcome from an instrumented spinal fusion.

Believe it or not, a validated questionnaire like the Oswestry scale is superior to imaging findings in measuring a construct like 'health'.

Physical therapists are getting better at using these measures.

The Criteria

The X Prize Foundation sounds like it is committed to a measure of health that is amenable to physical therapy interventions, namely
"good health based on better outcomes and an individual’s active participation.".
Proposals have to impact the lives of 10,000 people and improves their lives (health) by 50%. The measures used must meet the following criteria:
"...metrics will need to be at the community/ population level and objective and easy to track using validated tools, where possible...

We will weight the measures to place functional improvement at equal stature with sick care."
The Team Approach
Winning the X-Prize won't be cheap or easy but it may be worthwhile - are there any PTs up to the challenge?

Friday, April 10, 2009

Do Physical Therapists Make Decisions Like Doctors?

Anchoring, Availability and Attribution.

One medical student calls these the "3-A Mistakes" so she wont forget how doctors make mistakes.

In How Doctors Think Jerome Groopman, MD describes common cognitive errors that busy doctors make in diagnosing their patients.

Do physical therapists make these same mistakes?

Perhaps I should be more circumspect but I'll follow Dr. Groopman's lead and share with you how at least one physical therapist committed cognitive errors in the diagnosis of a physical therapy patient.

I'm that physical therapist.


First, I'll define the terms Anchoring, Availability and Attribution - types of cognitive errors made by all professional decision makers and not unique to medical doctors or physical therapists.

Anchoring - is seizing upon an initial presenting symptom and making a snap judgment about the diagnosis.

My patient was a middle-aged African-American female with leg pain radiating to, but not past, the knee. Many of my patients with radicular leg pain, past the knee, have been successfully treated with lumbar traction.

My anchoring error occurred when I lumped my poor patient into a traction classification based on what I thought was radicular leg pain which I did not investigate thoroughly enough to find that the radiation stopped just above her knee - referred, but not always radicular pain.

I 'anchored' my decision to use traction based on her leg pain, assigning a high probability that she would improve after the treatment,

Availability - is estimating the probability of a diagnosis based on how easily an example of a recent patient can be brought to mind.

As I've said, many of my patients got better with spinal traction - their successes were fresh in my mind. Many on my patients with referred leg pain had initially presented with pain all the way to the foot and, with treatment, their pain had worked its way back up the leg - occasionally presenting as 'leg pain to the knee'.

My cognitive error was simply because I had many other patients who responded well to traction that my poor patient would also respond well to traction.

Because my experiences were mentally 'available' I was able to quickly decide based on a vivid memory rather than actual statistical probability.

Attribution- is similar to Confirmation bias, where information that confirms one's beliefs is highlighted and information that contradicts prior beliefs is ignored.

Since my poor patient had a referral from her orthopedic surgeon that said 'consider traction for lumbar degenerative disc disease' I easily fell into the Attribution bias trap.

I didn't examine every patient characteristic that I normally do and I 'attributed' her leg pain to a pathologic diagnosis based on a reputable source.

I should have known better.

My Poor Patient

Needless to say, my poor patient didn't get better with lumbar spinal traction - she got worse. She could barely stand up when she got off of the table and it took her ten minutes to walk out of the traction room.

What did she have?

She was in a stabilization classification.

Upon further examination, my poor patient had a mild 'instability catch' and a positive prone instability test. See the full classification criteria here (Childs et al, JOSPT, 2007 June).

She is still seeing me and doing well with a stabilization program.

So, now you know my cognitive errors.

Anyone willing to share theirs?

Tuesday, April 7, 2009

Physical Therapy Diagnosis Redefined

In updating my Facebook page I've rewritten the mission statement for the Physical Therapy Diagnosis blog.

As my knowledge and commitment to my physical therapy patients and practice deepen and broaden through years of study so has my understanding of this blog: it's purpose and it's power to educate and inform go both ways.

Many thanks to those of you who have chosen to respond and comment to my posts - your voices have enlightened me.

Many thanks also to the readers (500 strong each week) who choose to read only - your surfing helps this blog rank well in physical therapy web searches.

Physical Therapy Diagnosis Redefined
Physical Therapy Diagnosis blog is a forum that speaks to the difficulty in doctor-level decision-making for physical therapists.

By 2020, the APTA Vision Statement calls for all physical therapists to be educated at the level of the doctor of physical therapy.

Physical Therapy Diagnosis blog does not assume that today's practicing physical therapists are making daily decisions of sufficient complexity and riskiness to qualify physical therapists for the title of doctor.

Therefore, the format, quality and tone of the content on this blog will be aimed at improving daily decision-making among physical therapists.

Together, let's help physical therapists improve the quality of their decision-making and assume the title of doctor.
Recently, I have been told that I do not have the credentials (eg: DPT,PhD, etc) to undertake such a mission.

That may be so. Please, say so in the comments if you like.

I have also been told that my content is valuable, spot-on and relevant in today's ever-changing health care market.

If you like the content please sign up for the free Bulletproof tutorial below.

If not, thanks for reading.

Sunday, April 5, 2009

A crisis in Physical Therapy?

Rahm Emanuel, the current administration's Chief of Staff wasn't the first one to say...
"A crisis is a terrible thing to waste"
...but he may go down in history as the one who gets credit for saying it, especially since he is already being quoted in the April 6, 2009 Newsweek as the one who said it.

Emanuel was iterating the point that right now is a great time to try new ideas to reverse past mistakes and reverse inequities in the current system.

Health care has made some mistakes and has some inequities that might be improved a bit.

Health care has room for some new ideas.

A Call for New Ideas

The latest (April 2009) edition of Physical Therapy Journal has an article by Shumway-Cook calling for a standard platform for the examination and intervention in patients at high-risk for falls.
"These findings suggest a need in the profession of physical therapy to identify and implement a consistent approach to management of falls due to physical factors such as reduced strength and impaired balance and gait among older adults."
Right now the profession is left to invent 'homegrown' methods for many examination measures, interventions and outcomes. Only 48% of physical therapists in the US use standardized outcome measures to assess baseline status and progress in their patients.

Don't misunderstand, I approve of invention and innovation - but I also need standardization. So do our patients.

Can it work?

There is substantial literature that shows physical therapists are able to identify persons at risk for fall and other disabling conditions before they suffer an episode and before they perceive a limitation.

Perhaps our screenings should encompass more than falls risk - perhaps we should look for limitations that hinder a persons ability to work and play to their fullest extent.

Many of my patients tell me that they are 'normal' - just 'old'.

We now know the following...
"although older persons did not perceive a limitation in performing certain tasks, they performed certain tasks less often" (Jette A, JRRD, 2007)
Try this on

Tax credits for older persons who pass certain validated and reliable performance measures administered by physical therapists.

For example:
  • Timed Up and Go Test
  • Functional Reach Test
  • Balance and Reach Test
  • Timed Tandem Standing
  • Timed Single Leg Standing
  • Timed Rhomberg Test
The expected health care savings (from reduced falls, fewer hospitalizations, less institutionalization and morbidity/mortality) would have to be estimated while the amount of the credit would be a real cost to the Federal government.

The amount invested (the difference between the cost and the estimated savings) could be compared to the amount now spent for proposed and existing programs, such as PQRI.

The upside

Physical therapists gain direct access to a new patient base that will see immediate benefit from our interventions while the government gains cost savings and a healthier, more productive, citizenry.

The patients wins all around.

It's time to stop wasting time.

What do you think?

Saturday, April 4, 2009

I saw Rosa today in PT...

little old lady

I treated a very sweet lady named Rosa today. Rosa weighed in at over 225 pounds at a little over five feet tall. Rosa presented in the clinic with her rolling walker and her daughter in tow.

Rosa had a physician employed by an insurance company who did everything she could to keep from sending patients to physical therapy because she was financially penalized for referrals to costly ‘ancillary services’.

Rosa had seen pain management, rheumatologists, internists and orthopedic surgeons for persistent unilateral rib pain. Rosa had fallen twice in the period she had been seeking help. She had refused injections and had asked for physical therapy on more than one occasion.

Rosa’s daughter insisted that her mother needed electrical stimulation. The daughter’s chiropractor used electric stimulation twice a month on the daughter's neck ‘for over a year’ to the daughter's apparent satisfaction.

Rosa could barely stand up in from the chair but she ended up that day with me doing many varieties of performance testing:
  • Timed Up and Go Test
  • Functional Reach Test
  • Balance and Reach Test
  • Timed Tandem Standing
  • Timed Single Leg Standing
  • a few impairment measures.
To Rosa's surprise, movement felt better. She could feel the spasms in her rib easing as I had her reach out over her base of support. I could see the daughter was visibly impressed at the tasks I was getting her mother to do.

Rosa left that day feeling better and didn’t get sore the next day. She declined the electric stimulation on the first visit because of time.

Patients like Rosa can often benefit with just one type of treatment intervention. In Rosa' case, reaching offered the greatest immediate benefit.

Rosa's Story is an Example

Rosa's story is an example of the clinical benefit offered by standardized testing. Also, each of the measures mentioned above produced a valid and reliable measurement. Some of the measurements have known change scores that reflect true change to assess progress. Finally, some of the measures are predictive for falls. Improving these measures should decrease the patients' risk of future falls.

Mock Audit

Our clinic started using predictive performance measures after we had a mock Medicare audit performed on five of our "Bulletproof" charts. The audit pointed out 'weaknesses' in our Medicare compliance program, namely, the insufficient use of performance measures in high risk populations.

Your clinic Medicare compliance program can benefit, as mine did, from following guidelines promoted by the Office of the Inspector General, namely:
  • Conducting internal monitoring and auditing;
  • Implementing compliance and practice standards;
  • Designating a compliance officer or contact;
  • Conducting appropriate training and education;
  • Responding appropriately to detected offenses and developing corrective action;
  • Developing open lines of communication; and
  • Enforcing disciplinary standards through well-publicized guidelines
The five charts I sent out for audit have been very helpful to me in upgrading, updating and further "Bulletproofing" my private practice physical therapy Medicare compliance program.

To learn more, sign up for the free Bulletproof PT decision-making tutorial below.

Free Tutorial

Get free stuff at BulletproofPT.com

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.
No reproduction without authorization.

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