"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

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?

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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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