Treatment Based Classification and Skilled Physical Therapy

Treatment based classification slipped past me in 2003 when the American Physical Therapy Association’s Combined Section’s Meeting came to Tampa, Florida.

The lead author of the original manipulation derivation study in the December 2002 Spine journal presented a talk titled “Spinal Manipulation Predictor Variables” – or something like that.

I saw the words ‘Spinal Manipulation’ and that lure was sufficient to get me to drive an hour from my home south of Tampa Bay, across the world’s second-longest suspension bridge (at the time) - the Sunshine Skyway, and attend, for $110, Dr. Timothy Flynn’s talk on how he discovered the first five predictor variables pertinent to physical therapy.

Dr. Flynn talked for an hour and no doubt said many things that passed over my head. His description was clear enough for me to understand, however, a few simple and liberating facts:

1. Lumbar spinal manipulation is a basic motor skill that should be taught to every graduating physical therapist in the United States.
2. Physical therapists can determine who can, and who cannot benefit, from lumbar spinal manipulation with five easy tests done in, perhaps, five minutes.
3. Lumbar spinal manipulation is low risk, high reward – when performed on the right patient.
4. Lumbar spinal manipulation is underutilized by physical therapists in the United States, Ireland and, by implication, the entire world.

Dr Flynn was especially clear in describing the sophisticated statistics that were used to derive the five manipulation predictor variables.

The explanation went thusly…

"...many potential predictor variables were tossed into a ‘hopper’ and the five that ‘fell out’ formed the parsimonious data set."

I went home a looked up ‘parsimonious’ in the dictionary.

Despite Dr. Flynn’s best efforts, however, I spent the next 2-3 years busy with other tasks not directly related to manipulation or classification.

Cold, Hard Reality

It was only in February 2006, when I purchased a three-office, seven-therapist private practice that I seriously began looking for a completely evidence-based solution to the looming threat of Medicare audits (Florida was a RAC Demonstration state, along with New York and California) that I began to understand the true importance of decision rules.

Medical decision rules hold the promise of improving efficiency without sacrificing safety, improving resource allocation, cutting costs and improving functional outcomes113,115-120,132,137 (bibliography).

Much of the push for decision rules in medicine has come from institutional cost constraints at large public hospitals like Cook County Medical Center in Chicago where Dr. Brendan Reilly found that many patients sent to intensive care cardiac beds costing $3,000 per night might have been better managed with a pack of Rolaids.

The US Navy was the initial funding source for Dr. Lee Goldman’s Chest Pain prediction rule in 1982, when no American hospitals were willing to support a narrow validation study based on the belief that a computer algorithm couldn’t compete with human doctors’ decisions. Perhaps doctors’ traditional conservatism played a role, perhaps pride, perhaps fear that a computer could do better medicine was what kept Dr. Goldman from finishing his work for 14 years.

The Navy, however, didn’t have 14 years. The Navy ran nuclear submarines under the ocean that had to stay submerged for days or for weeks at a time for reasons of national security. The Navy would surface the sub to get a sick seaman to a land-based hospital. The Navy wanted to know, definitively, if their able seaman with chest pain needed:

• A cardiac intensive care bed.
• A cardiac telemetry bed with round-the-clock nursing.
• A pack of Rolaids and a bunk.

Without bowing to culture, pride or conservative sensibilities the US Navy sponsored Dr. Goldman’s initial studies that focused, not on the diagnosis, but on the outcome of the doctors’ decision – that is, which bed did the doctor decide on?

Providing the doctor with clear-cut treatment choices to follow and with a decision rule that leaves little room for interpretation are examples of ‘systems thinking’ – the type of thinking that says that errors, including errors that lead to less-than-optimal outcomes, happen when good, well-meaning people make mistakes – mistakes like forgetting to run a certain test or check a certain vital sign. Mistakes in physical therapy are rarely life-threatening – they often only mean that the patient doesn’t get better even when no new harm befalls the person.

Treatment based classification provides the physical therapist with a checklist that ‘backs up’ the examination process and prepares the therapist for the evaluation. As stated by Lee Goldman, MD:

“The modern approach to patient safety emphasizes “systems thinking” rather than individual cognitive mistakes or technical “slips”.

The goal is to create processes and solutions to prevent human errors, which are commonly made by competent individuals”.

Some therapists consider TBC to be “paint-by-the-numbers” or, what we called “cookbook physical therapy”, – something we swore we would never do in high-minded discussions in physical therapy school or after work in comfortable surroundings.

What gets missed in some of these discussions is the fast-paced reality of the physical therapy clinic where decisions get made on-the-fly, based on symptoms, or patient complaints, or lack of progress, or “that’s-what-I got-from-Joe-last-time” or “what-do-I-do-now?” While we all want to think that we can make decisions true to our biomechanically-correct hearts and to our patients’ needs the truth may be closer to the research of Atun Gawande, MD:

“Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes. The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly. It is unduly swayed by desire and emotion and even the time of day. It is affected by the order in which information is presented and how problems are framed.

And if we doctors believed that, with all our training and experience, we escape such fallibilities, the notion was dashed when researchers put us under the microscope.”

Why do Doctors Distrust Clinical Prediction Rules?

Medicine is a profession of people caring for people. For all the science, statistics, dollars and debates that go on about who should get it and who should pay for it the essential interaction in medicine is the face-to-face encounter with the patient in front of the doctor saying, “I need help”.

Help is what we provide be it in counseling, coaching, supportive care, surgery, physical therapy, pharmacologic agents, mental health services or end-of-life hospice care. Help is an emotional word.

The problem, as I see it, is that treatment-based classification is seen as a completely emotionless, distant process:

1. assess pre-test probability (example: stabilization sub-group 33%)
2. measure predictor variables
3. apply treatment
4. Bye bye

Chris Anderson, in The Long Tail, describes probabilistic systems, like Wikipedia, Google and classification predictor rules as…

“…operating on the alien logic of probabilistic statistics - a matter of likelihood rather than certainty.

But our brains aren’t wired to think in terms of statistics and probability. We want to know whether an encyclopedia entry is right or wrong. We want to know that there’s a wise hand (ideally human) guiding Google’s results.

We want to trust what we read.”

Anderson describes a phenomenon that is evident among clinical physical therapists and physicians who resist “cookbook’ medicine wherein algorithmic simplicity seems to disregard the face-to-face complexity that characterizes (and sometimes confuses) clinical care.

The Crisis of Complexity

The Second Ecumenical Council of the Vatican, or Vatican II, opened under Pope John XXIII on October 11, 1962 and closed under Pope Paul VI on December 8, 1965.

Vatican II was destined to become known as the “opening of windows” when the Church would become open to all. Masses would now be said in native tongues instead of Latin, laws proscribing rewards and punishment rescinded in favor of ‘flexibility’ and ‘participation’. Catholicism became ’relative’ to one’s personal desires.

Attendance at Catholic Masses dropped 50% between 1964 and 1981. The Church was losing its influence.

Al Ries and Jack Trout were public relations consultants working in Atlanta, Georgia at the time when they were contacted by a group of lay persons who were concerned about the Catholic Church’s position in the minds of the people.

The laity asked Ries and Trout to help them answer this simple question…

“What is the role of the Catholic Church in the modern world?”

The Church had thought that their role was to be the ‘Teacher of the Law' while Ries and Trout found that the people (and, indeed, scripture) found that the role of the church was to be the ‘Teacher of the Word’.

‘Word’ vs. ‘Law’

Seems like such a simple, obvious distinction, doesn’t it?

Ries and Trout believe that simple positioning statements best clarify organizations and ideas in the minds of people. However, church leaders seemed to prefer their role as teachers of the Law:

“Experience has shown that a positioning exercise is a search for the obvious…

...The human mind tends to admire the complicated and dismiss the obvious as being too simplistic”

Did the Catholic Church change to become teachers of the Word? Not according to Trout and Ries. What happened to the Church since 1981? The results seem evident.

Classification predictor rules, despite their statistical challenge, promise to simplify clinical physical therapy decision-making in a way that challenges the established clinical order.

The Skilled Process of Classification Prediction Rules

‘Skilled’ physical therapy segued from inpatient facilities to outpatient settings in the early part of the 21st century as one of the answers to the problem of yearly 30% increases in ‘per beneficiary’ costs. Each outpatient physical therapy Medicare patient was increasingly consuming more and more services.

In order to control costs, Medicare would more stringently monitor the 'process' of outpatient pysical therapy care.

Skilled physical therapy initially meant ‘safety’ in the provision of the following:

1. movement
2. ambulation
3. range-of-motion
4. bed mobility
5. pressure relief

...in settings where patients with multiple, chronic and progressive conditions might not be expected to show ‘progress’. When the ‘skilled’ concept began to be applied to outpatient physical therapy it came with adjunctive requirements of supervision like the following:

• “8-minute rule”
• timed vs. un-timed codes
• ‘59’ modifiers

Medicare auditors in outpatient physical therapy now look for safety and progression in the therapists’ note as evidence of ‘skilled’ care. One of Medicare’s definitions of ‘skilled care’ (there are more than one):

“Services must… require, for example, the expertise, knowledge, clinical judgment, decision making and abilities of a therapist that assistants, qualified personnel, caretakers or the patient cannot provide independently.

A clinician may not merely supervise, but must apply the skills of a therapist by actively participating in the treatment of the patient during each Progress Report Period.

In addition, a therapist’s skills may be documented, for example, by

• the clinician’s descriptions of their skilled treatment
• the changes made to the treatment due to a clinician’s assessment of the patient’s needs on a particular treatment day
• changes due to progress the clinician judged sufficient to modify the treatment toward the next more complex or difficult task.

A therapist’s skill may also be required for safety reasons…”

Is Classification a Skill ?

Let’s look again at my brief tongue-in-cheek vignette on how to apply CPR’s:

1. assess pre-test probability (example: stabilization sub-group 33%)
2. measure predictor variables
3. apply treatment

Measuring predictor variables is not new and one could argue that measurement is a skilled component of the physical therapy service. Most of the predictor variables are self-report or historical findings ‘mashed up’ to form the CPR.

Applying treatment may or may not be skilled, depending on the treatment and the degree of repetition the Medicare auditor finds in your chart. Remember, Medicare expects the physical therapist to document ‘progression’ in the note as a means of establishing ‘skill’.

We are not yet paid for outcomes so we will still be judged on the process by which we provide care.

I was once called by a physical therapist undergoing a Medicare audit asking for help – she couldn’t understand why she was being audited when she spent nearly one hour (and charged 4 units) with each patient, giving massage and ‘myofascial release’, because they were ‘so much worse off’ than the ‘average’ Medicare patient. Her services were repetitive in nature, not restorative. Her argument was that she needed to provide so much massage in order to get her patient ‘ready’ to participate in restorative exercise.

Her patient population was unique but not in the way that she described it.

Because each physical therapists patient population is unique I believe there is an opportunity to provide a skilled service unique to each physical therapist: estimation of the size of the pre-test probability.

For example: the derivation study for the lumbar stabilization CPR had a pre-test probability of 33%.

Evidence-based medicine precepts would have me compare my patient population to the study population described by Hicks before applying the stabilization CPR.

Hicks’ population had the following:
1. Mean age of 42 years
2. 57% female
3. 41 days duration of symptoms
4. 46% had distal symptoms
5. 33% had a sudden onset
6. Average pain (VAS) 4.5 points.
7. Baseline Oswestry scale 30 points
8. Baseline Fear Avoidance Beliefs – Work 14 points
9. Baseline Fear Avoidance Beliefs – Physical Activity 15 points

My population has the following:
1. Mean age of 57 years
2. 61% female
3. 18 days duration of symptoms
4. 55% had distal symptoms (higher rate of compressive dysfunction)
5. 23% had a sudden onset
6. Average pain (VAS) 5.5 points.
7. Baseline Oswestry scale 42 points (greater disability)
8. Baseline Fear Avoidance Beliefs – Work 7 points (retired persons don’t work)
9. Baseline Fear Avoidance Beliefs – Physical Activity 18 points

Unique factors about my population may also include the following:
• Retirement community
• Southern climate (lots of flip-flops and sunburns)
• 60% Medicare (lower out-of-pocket but fixed income)
• Second-highest rate of spinal fusion surgery spending in the United States (Bradenton-Sarasota MSA)

Let’s say I get a patient with 3/4 predictor variables for success with lumbar spinal stabilization. Hicks’ algorithm gives a 4.0 positive likelihood ratio (+LR) which implies about a 30% upward shift in probability favoring stabilization – assuming my population is exactly like his.

But, I think my population is different: older, stiffer, has a higher incidence of spinal compressive disorders, more disability and more co-morbidities. I think I should adjust my pre-test probability of stabilization responders downward – but by how much?

There are two ways to find the pre-test probability for your population. The first way is to adjust published estimates based on heuristics, or ‘rules-of-thumb’. My population is about 1.5 times older than Hicks’ population and correspondingly stiffer so I could adjust Hicks’ pre-test probability down by the inverse of 1.5 (67%).

The other way is to generate a 2x2 table, test everybody, apply the CPR and assess the responders and non-responders. You will be able to calculate your own values for sensitivity, specificity, pre-test probability, post-test probability, positive and negative likelihood ratios.

Since I have a full caseload and little time for outside research I will use the heuristic adjustment to Hicks’ rule:

33% x 0.67 = 22% adjusted pre-test probability

¾ predictor variables in Hicks' classification has a +LR = 4.0 which shifts probability upward approximately 30% .

30% + 22% = 52% adjusted post-test probability

…which is little better than chance. I could do about as good flipping coins and allocating patients to lumbar stabilization or some other treatment.

So, Is This Skilled Physical Therapy?

Whether or not I choose to use stabilization I think that using Hick’s rule implies that, yes, my care is skilled.

In outpatient care our only competitive advantage is that we are closer to and more in contact with our patients than in other settings, which tend to be larger, institutionalized settings. We need to know our patients better than anyone else.

Steven McGee, MD argues convincingly that the use of likelihood ratios requires greater patient contact and understanding, not less:

“…because the best estimate of pretest probability incorporates information from the clinicians’ own practice – how specific underlying diseases, risks and exposures make disease more or less likely – the practice of evidence-based medicine is never “cookbook”.”

We measure what can be measured in order to quantify the impact on the pre-test probability. Physical therapists need a ‘culture of measurement’ in order to routinely collect and understand these data.

Observation and Classification

Kepler's First Law: Planets move in ellipses with the Sun at one focus.

Kepler's First Law has applied to space scientists and astronomers since it was discovered over 430 years ago. Yet, Johannes Kepler didn't gather much of the data upon which he based his discoveries. Kepler was nearly blinded by smallpox before he was five years old.

As the Imperial Mathematician to the Holy Roman Emporer, Kepler couldn't quite see the stars he decribed in his first book, Astronomia Nova (1609), but he had faith in the measurements and in the observations of Tycho Brahe, his first patron and the man who generated much of the data for Kepler's initial insights.


Because of his eyesight, Kepler relied on Tycho Brahe's measurements of the stars and was able to derive equations that described the motion of the planets around the Sun. Keplers' Laws of Planetary Motion still hold today and are used for planning rocket launches and managing satellites in orbit. The word 'satellite' was coined by Kepler. Kepler's work is held in such esteem that he rates a page on NASA's website.

Kepler used observation and insight to create The Laws of Planetary Motion in an age before probability and computerized computation. His planetary tables...

"...used logarithms, which he developed, and provided perpetual tables for calculating planetary positions for any past or future date."

Observation and insight have generated tremendous discoveries in science, indeed, the entire Scientific Method is based on intial observations, predictions, hypotheses, measurements and tests.

Observation in Physical Therapy

The temptation to adhere to observation as the basis for physical therapy discovery in patient care is strong. What can treatment-based classification (TBC) offer more than your clinical observation when you can see, hear, smell, touch, taste (?) and talk to the patient right in front of you?

Some classification predictor variables predict an outcome like spinal manipulation success with 95% confidence. But the predictor variables are themselves uncertain - derived by dumping plausible tests into a 'hopper' (derivation study) and seeing what 'falls out'.

How can these statistically derived variables compete with the observation that the patient who says "I hurt" can feel better from your hands-on care? Who gets to decide what treatment is most appropriate?

Physical therapists on Soma Simple Discussion Boards demonstrate some of the controversy around TBC.

Why is it no surprise that even accomplished physical therapists have trouble wrapping their arms around classification? Peter Huijbregts, PT talks about his struggles with this paradigm shift in the Journal of Manual and Manipulative Therapy (2007):

"The once predominant mechanism-based classification system that is based on the premise that impairments identified during examination are the cause of musculoskeletal pain and dysfunction is increasingly being replaced by treatment-based classification systems.

In the treatment-based system, a cluster of signs and symptoms from the patient history and physical examination is used to classify patients into subgroups with specific implications for management."

People have always been uncomfortable with probabilistic systems, even among scientists. Some examples of probabilistic systems that have excited controversy and generated debate in the time since Kepler include the following:

1. Wikipedia vs. Encyclopedia Britannica
2. Free Market Economics vs. Central Planning
3. The Theory of Evolution vs. Religiosity
4. Google vs. what?

Probability implies that we are never 100% certain that the measurement describes the patient or the outcome - we can only know our level of confidence across samples of patients.

The Wikipedia Phenomenon (from The Long Tail)

Wikipedia articles have been described as 'amateur' or 'inaccurate'. However, a study done by the journal Nature found that Wikipedia averages 3.86 errors per article compared to 2.92 errors per article for Encyclopedia Britannica . Wikipedia article are corrected daily - as soon as the error is spotted. Encyclopedia Britannica articles only get corrected at new, printed editions - about every ten years.

Wikipedia has 13 million articles - Encyclopedia Britannica has just over 250,000. The chances that you will find an up-to-date article about something interesting in Wikipedia are pretty good. The Wikipedia article on 'Physical Therapy' is 4,659 words long. The Encyclopedia Britannica article on 'Physical Therapy' doesn't exist.

Growth Rate of Wikipedia Articles

Wikipedia is a probabilistic device that succeeds because it is useful to most of the people, most of the time. Encyclopedia Brittanica is an authoritative device that, until now, was our only option for encyclopedic information.

Authoritative Decision Makers

We still need authoritative sources like Encyclopedia Britannica but their dominance in information search is over. I recommend starting your information searches with Wikipedia and finding more authoritative sources as you delve deeper into your studies.

The ability of scientists to find amazing discoveries based on obsevation and insight has waned and so too has the dominance of physical therapists who insist that their palpatory and visual findings are superior to probabilistic tools like TBC.

Prediction of Risk

Another type of prediction physical therapists use can be called 'risk-adjusted prediction' where baseline data such as...

1. age
2. impairments
3. self-report scores
4. co-morbid factors like fear

are used to predict an outcome such as...

1. self-report change scores
2. predicted total number of visits
3. predicted total duration of care

Risk predictions are made by comparing your patients' baseline data to millions of similar patients in a database - your patient, whose characteristics match some of those patients in the database, is 'predicted' to get better, in scope and rate, like the patients in the database.

Risk-adjustment is not as cold and calculating as it sounds. Physical therapist J.W. Matheson believes he is a better physical therapist by using this tool.

"I find great value in this information and believe that it helps improve my communication and care of my patients.

We spend time during the initial evaluation discussing aspects of their risk-adjusted outcome data, and psychosocial yellow flags can be identified immediately.

More efficient care and utilization of staff and services is the end result."
(IMPACT June 2009 PPS log-in required)

For the non-mathematician/statistician (I am a 'non') it may feel like we are being asked to cede our decision-making control to algorithms and databases on 'faith'. Faith in the science and the statistics behind classification is what we fellow 'nons' are asked to trust.

Johannes Kepler trusted Tycho Brahe's data because he couldn't see. But, Kepler used Brahe's data to create better tools that predicted the future pathways of planets and allowed future space scientists and astronomers to see further than ever before.

What future pathways will physical therapists predict using probabilistic tools?

Why Can't Connor Ride His Bike?

My eight-year old son has a friend named Connor. Connor is a normal eight-year old boy except in one respect.

Connor can't ride his bike.

Connor is in physical therapy at school working on gross motor control, lower extremity strengthening, jumping, hopping and climbing activities. I've seen Connor run - he's a bit slow but otherwise normal. Jumping is a bit awkward but he makes it. Hopping is status quo.

So, why can't Connor ride his bike? Why does he walk when all the other neighborhood kids ride by - leaving him pushing his bike?

It turns out that Connor is scared of falling off of his bike.

Connor fell of a smaller bike when he was two years old and broke his arm. He has been scared to ride his bike ever since. His mom has asked many of the neighborhood dads (even Connor's karate instructor) to help Connor get over his fear. I've tried to work with him a few times.

Connor seems to demonstrate what Hart et al describe as...

"Evidence (of the) possible existence of fear avoidance beliefs or pain-related fear in people who have other impairments or who may not have pain, perhaps because of learned behavior after previous painful episodes or misconceptions about pain."

In Screening for Elevated Levels of Fear-Avoidance Beliefs Regarding Work or Physical Activities in People Receiving Outpatient Therapy in the August Physical Therapy Journal Hart et al found that fear avoidance beliefs can be described as High or Low (rather than a score) and that one screening question can measure the level (rather than 21 questions in the Fear-Avoidance Beliefs Questionnaire - FABQ).

What Can You Do?

Physical therapists can find out if musculoskeletal pain patients have elevated fear-avoidance beliefs early in the course of care so that reducing the level of fear-avoidance becomes a goal of therapy.

The fancy term for reducing fear-avoidance beliefs is Cognitive Behavioral Therapy (CBT) which is a distinct psychological specialty but one from which physical therapists might be able to learn some management strategies for chronic pain patients.

Hart et al recommend the first step is to screen your patients for high levels of fear-avoidance with these two, simple statements:

1. "I should not do physical activities which (might) make my pain worse."
2. "I should not do my normal work with my present pain."

Statement #1 predicts the response (high/low) on the Physical Activity sub-scale. Statement #2 predicts the response on the Work sub-scale.

We've used the FABQ (21-item) but now I'm making these statements a part of my intake patient (self-report) forms that will be indicated with checkboxes indicating agreement or dis-agreement.

Co-morbid factors like fear-avoidance, age, depression and self-reports of function turn out to be bigger drivers of chronicity, cost and resource utilization (eg: PT visits) than traditional impairment measures like strength, ROM and swelling.

Physical therapists may be able to improve overall patient management and increase reimbursement by screening for fear-avoidance at the first and last visit.

Just as important, we may be able to more accurately detect those at risk - those people like Connor.

Mo' money

Treating fear-avoidance early in the course of care may allow physical therapists to 'risk adjust' an episode fee capped at, for instance, ten visits for uncomplicated lower back pain.

Today, all of your Medicare visits are reimbursed fee-for-service (FFS) but nobody expects Medicare FFS to last much longer in its present state - nor is Medicare FFS sustainable if it does last past this current legislative session.

Al Amato, PT wrote an article in IMPACT (PPS log-in required) called Value Purchasing in Physical Therapy in March 2006 that described the effect of risk adjustment on an alternative payment system. Mr. Amato wrote...

"Risk adjustment allows the comparison of a patient with a specific profile to a similar risk-adjusted group of patients in a large database.

This allows the ability to predict the efficiency and effectiveness of an individual treatment because of the profile of the similar risk-adjusted group of patients from the national database."

In the future, you will need to identify which patients are likely to have poorer outcomes (based of elevated fear-avoidance beliefs) but you will be able to request more treatment sessions. Or, you can treat the elevated fear-avoidance beliefs from baseline, get the patient better in fewer visits - and get paid a bonus.

Who Could get Better by Learning About Fear?

In 2007, there were 97,900 outpatient therapy providers billing the Medicare program in the United States: about 19% of these are Occupational Therapists and 7% are Speech Language Pathologists (table 7 & 10).

The intent is to transition all of these providers to a 'value based' payment program that allows providers to succeed and patients to get better.

Hart's study is a big step in the direction of value-based payment (Hart and Amato work for the same company) because this study shows clinicians how to quickly and accurately screen people like Connor for elevated fear-avoidance beliefs.

Improved screening for this, and other, psychosocial factors that influence chronicity can improve the effectiveness and efficiency of our physical therapy treatments.

Physical Therapy Insight

You are confronted by the patient with intractable chronic pain – you’re the therapist – What do you do? What do you decide?

Bulletproof Physical Therapy Decisions presents your decision as the ‘skilled’ component of the physical therapy encounter. And there are two types of decision you can make.

Physical therapy decisions are dichotomized into two domains to draw attention to insight decisions – decisions that occur in the blink of an eye and can’t always be explained by logic or supported by data. Physical therapists have, historically, based many treatment decisions on insight and many patients have benefited from these treatments.

Non-Insight Decisions

Recent years have seen an explosion in physical therapy research into clinically relevant tests and measures like self-report, performance and classification measures.

Tests and measures that generate patient data by self-report, performance testing, classification and even ‘old school’ impairment-level measures are ‘obvious’ decision support tools and most are far better than what I had when I graduated with a 4-year Bachelors in Health Science in 1992.

Back then, you could explain your choice of a spinal traction treatment by pointing to the evidence from your examination:

• Signs of nerve root compression in the leg or arm such as
1. altered sensation
2. asymmetric reflexes
3. segmental motor weakness
4. unilateral muscle atrophy.

Now, we have classification predictor variables that indicate which patients will ’probably’ get better with a lumbar manipulation.

My Insight

Insight decisions are difficult to explain, hard to teach and challenging to document – why not manipulate a lumbar patient with 4/5 positive predictor variables for manipulation? What is it about his presentation that gives me pause? Is the manipulation worth the risk?

This lumbar patient also had a positive sciatic tension test and a positive cross leg sciatic tension test – tests these are not predictor variables for any classification category, not even ‘contra-manipulation’. Yet, these tests are sensitive and specific for lumbar herniated nucleus pulposis. The patient also had a lateral shift – which is a predictor variable for a direction-specific classification.

So, I had some tests that clearly pointed out why I shouldn’t manipulate and some tests that indicated the patient belongs in a different classification but why did I bother to examine those items in the first place?

One of the promises of a classification approach to physical therapy is its reliance on a parsimonious data set of predictor variables – fewest data are better. Therapists can quickly gather data on complex patients and allocate their clinical resources (eg: time) to do the most good. Presumably ‘the most good’ means better patient satisfaction, lower costs or improved outcomes using standard self-report measures.

So, insight decisions are an important source of clinical wisdom that is difficult to quantify and write down. Nevertheless, we ought to listen to our insight and, more importantly, study how those decisions are made so we can improve our teaching and documentation.

A Puzzle

Before I go on, I’d like to present an example of an insight puzzle.

This example is taken from Malcolm Gladwell’s bestselling book on decision making, Blink.

A man and his son are in a serious car accident.
The father is killed and the son is rushed to the emergency room.
Upon arrival, the emergency room doctor looks at the patient and gasps, “This child is my son!”
Who is the doctor?

The doctor is the child’s mother.

Most of us assume that the emergency room doctor is a man. Not all doctors are men – of course. Since the emergency room doctors’ gender is not explicitly stated in the puzzle to get the right answer we need to use our insight.

The Problem with Insight

Bulletproof is about how physical therapists can make better decision, primarily with better data, but also through insight – and write down their decisions to show skill, progress and need.

However, the very act of writing down your thought impairs your insight into the problem!

Psychologist Jonathan Schooler studied people’s performance on insight puzzles by interrupting their work and asking them to describe their thought processes – how did they reach their conclusions? What steps did they take? Did they make mistakes and start over?

He then repeated the experiment but this time he asked the subject to stop and write how they arrived at their insights.

With both experiments Schooler found that his subjects were able to answer fewer insight problems (Schooler calls insight problems ‘non-reportable processes’) when they were interrupted and asked to describe, verbally or in writing, their thought processes.

Schooler’s control groups were also interrupted and asked to stop working on their insight problems for the exact amount of time the experimental groups were asked to describe their thought processes.

The experimental groups, both verbal and written, were able to solve 30% fewer insight problems than the control groups. Schooler call this effect verbal overshadowing 121.

Face recognition is another area of study by those, like Dr. Schooler, who study insight.

I’m going to ask you to picture the face of someone you know, but not personally, say a famous movie star like Brad Pitt. You probably have his face in your mind right now. You can see his eyes, his hair, his chin. But, how accurately could you describe him to another person? Would they recognize Brad Pitt from your description?



By verbalizing your insight into facial recognition you weaken your insight. Face recognition and insight word problems are just two areas where insight has been shown to be impaired by verbalizing and writing 121.

What Implications do Overshadowing Have for Physical Therapists?

Plenty.

If you are comfortable and conversant with the leading edge of physical therapy practice (as of the writing of this book) in areas like treatment-based classification (TBC), performance measurement, self-report measurement, electronic documentation, alternative payment systems and Medicare compliance then you should have no trouble generating a daily note and a chart that accurately describes your interventions, patient need, expected progress and your skill level, even your insight decisions.

In 2006, when I bought out my private practice partners I was only peripherally involved in these issues. I was very much dependant on clinical insight, pattern recognition, heuristics and ‘rules-of-thumb’ to make decisions. If you are like I was then you should take heed…

The future of physical therapy will become increasing dominated by the clinicians’ ability to generate meaningful numbers (data) that justify our skilled interventions.

What about insight?

So where does that leave insight?

What about the valuable contributions made by legions of clinicians who came before we had of all these new, powerful probabilistic and predictive tests?

What about the patient in the example I gave earlier who presented with 4/5 predictor variables for manipulation and negative imaging studies? Why didn’t I manipulate him?

I can’t say for sure (since I had to write down my findings in the chart) but I suspected that he had an acute, torn disc. I gave him a Straight Leg Raise Test and then, on the opposite leg, I gave him a Crossed Straight Leg Raise Test – both were positive. The combination of these two tests, in populations with suspected disc injuries, is both sensitive and specific for herniated nucleus pulposus. I called his doctor and asked for a Magnetic Resonance Image (MRI). The results were positive.

What if I had manipulated him? What if I had not listened to my insight?

Medicare Demands Data

The standard of care in physical therapy in the United States is increasingly being provided by doctors of physical therapy practicing evidence-based medicine using clinical algorithms, classification and all the other tools just mentioned.

The prudent physical therapist is wise to incorporate these tools into her clinical examination, daily notes and complete chart.

How then can we preserve our insight yet create complete, compliant charts?

Here are five strategies I use to create a Bulletproof decision for my daily note and my chart.

Take Measurements Daily

I was taught to take measurements weekly or at least monthly. Now, when a patient fails a performance test the test becomes a part of the plan of care. For example, the Sharpened Rhomberg Test is an evidence-based measure used to predict falls and future institutionalization in elderly people. The test is valid and reliable and responsive to your clinical interventions. Why not, instead of just doing the technique, write down the score daily? Then you can show need (based on future falls risk) and change (based on the Minimum Detectable Change (MDC)).

‘Trust but Verify’

Classification decision-making is based on a parsimonious data set – that is, no test is used unless it is predictive and only predictive tests are used. The danger of a parsimonious data set is that patients aren’t data points – patients can’t be fully described with five (or seven or ten) predictor variables. Treatment (or non-treatment) risk may not be fully encapsulated by predictor variables.

For example, lower back pain patients often suffer from complexities and co-morbid conditions such as obesity, a sedentary lifestyle, various diseases and fear of movement. These patient often benefit with interventions that emphasize ‘spine sparing’ techniques, abdominal bracing, spinal stabilization and activity modification to identify provocative and easing factors of the pain. Some clinicians might call this approach a ‘stabilization classification’ yet, anecdotally, I have noticed that many lower back pain sufferers are older, stiffer and present in various stages of acuity. In short, few older patients satisfy most of the predictor variables for the ‘stabilization classification’.

Just like the manipulation patient I described earlier I measure all the stabilization predictor variables and use the classification decision rule as one of my tools – I make the final decision.

Put Goals up Front

I used to write goals because I had to – as long as the patient felt better I felt like I had done a good job. I didn’t understand the motivating effect goals can have on patient satisfaction. I also didn’t understand how important meeting functional goals is for a Medicare audit.

Now, we put a paper copy of our goals list on the front of the chart to refer to every treatment session.

In my clinic we co-treat our patients. I routinely delegate treatment to Physical Therapy Assistants who implement my Plan of Care.

1. Up-front goals are essential when flipping through a paper chart during a busy day.
2. Up-front goals keep everyone focused on what’s important – function.
3. Up front goals encourage the PTA to take daily measurements (see above).
4. Up front goals send a message to the Medicare auditor when the chart is audited that goals are important.

Spend face time with the patient

1. Insights happen when you least expect them – that’s what makes them insightful.
2. Insights happen when you are talking or listening to your patient.
3. Insights happen when you are reviewing patient data in the chart.
4. Insights happen when you are laying in bed that night remembering what else you could have done for your patient.

Yet, these insights rarely happen if you aren’t thinking about your patient or don’t remember your patient or never knew enough about your patient in the first place to understand her condition. To know these things we must spend face time with our patients.

Face time is good for your Medicare compliance program also – much time and talk have transpired at meetings, electronic list-serves and blogs about the one-on-one (constant attendance) requirements.

Here is an example of a recent answer to many of the questions about constant attendance asked in these forums:

“In the same 15-minute time period, one therapist may bill for more than one therapy service occurring in the same 15-minute time period where "supervised modalities" are defined by CPT as untimed and unattended -- not requiring the presence of the therapist (CPT codes 97010 - 97028). One or more supervised modalities may be billed in the same 15-minute time period with any other CPT code, timed or untimed, requiring constant attendance or direct one-on-one patient contact. However, any actual time the therapist uses to attend one-on-one to a patient receiving a supervised modality cannot be counted for any other service provided by the therapist.”

Spending your clinical time face-to-face with your patient will improve your compliance and your insight.

Write for posterity

Assume you may come back to read your own notes – or worse, someone else will. I am amazed when I go back and read some of my notes from 10 years ago – not much data.

My notes from three years ago, however (when I started Bulletproof), contain valid, standardized tests and measures on impairments, performance and self-reports.

Many of the tests I use reveal persistent impairments in ROM, strength, physical function and important self-reported activities – I have monitored one of my running patients from initial presentation of ‘trochanteric bursitis’ to ‘I-T band syndrome’ to’ torn anterior hip labrum’ over eleven years – all the while coaching and treating him so he could continue to run his marathons. I also advise him to cross-train on the cycle and in the pool.

The point is that his numeric data are remarkably stable – his values for, say, hip internal rotation ROM don’t change all that much over eleven years. His stiff right hip from eleven years ago is still his stiff right hip today.

Physical therapy helps him maximize his activities and the data I generate help me make decisions.

The Bottom Line

There is still room for insight in physical therapy – actually, the need is even greater since patients are more complex, the workflow busier, the risk higher and the decisions harder.

Insight, however, needs to be the last piece of the puzzle, the bottom line of a page full of data.

Some Red Wine with Your Physical Therapy, Sir?

I don't normally use red wine during my physical therapy sessions (I am a physical therapist). But, these examples of physical therapy from Spain may illuminate the American discussion on health care reform. My information for this blogpost comes from interviews during a 13-day trip to Spain this July.

You can get a massage at the Mondariz Balneario Hotel and Spa for about €25 (about $35.89 US dollars).

The cash price for "Vinoterapia Corporal" (Wine Therapy for the Body) at Aguas Santas Hotel Balneario (Saint´s Water Hotel and Spa) in Lugo, Spain is €42 (euros) - about $60.53 US dollars.

The cash price for "Fisioterapia Valoracion y Tratamiento" (physical therapy evaluation and treatment) is €47 - about $67.73 US dollars. A "Chocolate Facial" is €25 while a full-body massage is €35.

My wife has started to enjoy trips to places like Aguas Santas since our kids were born - nobody takes kids to places like this.

Both the Mondariz and Aguas Santas are located in Spain which offers 100% universal healthcare to it´s Spanish citizens and it´s immigrant amnesty beneficiaries.



Therefore, nearly every legal permenant resident in Spain has a basic level of health services available to them and their families. The Spaniards I spoke to said they were happy with their healthcare - they usually paid zero out-of-pocket:

Suso, a 45-year old artist-turned-student said that all of his friends and family had healthcare. Suso recently returned to school to learn a new career (printmaking) and both he and Mari, his wife, were able to maintain a health safety net.

Who gets Wine and Chocolate?

So, if physical therapy is free to those who need physical therapy then who is paying for wine and chocolate?

I talked to some local people: a police officer, an assembly line auto worker, a clerk in a nursing home and several physical therapists. This report represents the experiences of about a dozen people receiving and giving PT services from both hospital and private practice PT in the northwestern Spanish region.

The Results

Some of the Spaniards perceived some differences in outpatient physical therapy, depending on who paid the tab - here are some of their statements:

1. 20% of outpatient private practice physical therapy was paid by private insurance (non-Medicare).
2. 80% of outpatient PT was cash.
3. Physical therapists often decided to assign home exercises and modalities to Medicare patients.
4. Physical therapists often decided perform massage, mobilization and manipulation for private pay patients.
5. Private insurance paid better (I didn´t get access to a private fee schedule, unfortunately).

Medicare audits are a fact of life, just like in the USA, according to Jose, a hospital-based PT.

I asked another physical therapist, Gaspar of Viterapia, if Medicare patients were treated different because Medicare payment were so low. I expected to hear the worst but I was happy to hear Gaspar emphatically deny that patients received any different level of care. Gaspar did not, however, see Medicare patients in his private practice - only at the hospital where he worked occasionally.

Most solo physical therapists in private practice, I got the impression, did not see Medicare patients privately.

Only two PT providers in Vigo, a city of 300,000 on the cold azure, shores of the North Atlantic, saw outpatient Medicare using the volume-model of PT production to make economic sense by seeing 20 or more patients per PT per day. These clinics saw the Medicare in exchange for 125-600 referrals per month, it was rumored. Gaspar, in contrast, was able to run a nice, 2-PT clinic with one office girl to answer phones and book appointments. He saw 12 patient per day. His rates varied from €25 to €55 per visit.

Also, Gaspar told me he takes no notes, no chart, no documentation - patient clinical records are kept of a 3x5 index card with name, physician's diagnosis, and a little else.

Gaspar takes 80% cash pay in his office. Gaspar's private clinic opened at 8:30-1pm, then they took a siesta (really!) and re-opened at 6pm-10pm (really!). And,yes, it's OK to enjoy a glass of red wine at lunch, in Spain.

I met Gaspar at 9:30pm in his last appointment slot and afterwards we went to a little cafe for the interview.

Since Gaspar did not take Medicare he said he did not have to worry about audit risk. Gaspar's private pay patients did not need a physicians' referral to get physical therapy. All physical therapists in Spain are licensed and their license is signed by the King of Spain - that means no variations in practice act regulations depending on your address.

Medical necessity for physical therapy is still performed by physicians since physicians perform all of the evaluation, testing and measurements.

Jose (the hospital PT) didn´t use any self-report, performance-level or classification measurements in the treatment plan. He did cite Florence P. Kendall´s Muscles: Testing and Function With Posture and Pain (the book, first published in 1949, has been published in eight languages). Jose said he did perform Manual Muscle Testing on his patients.

Gaspar performed mainly massage and mobilization - he had just finished a Freddy Kaltenborn course in Zaragoza. The Spanish PT association paid for part of Gaspar's course.

Gaspar was familiar with some performance tests, such as Single Leg Support, Sharpened Rhomberg, Timed Up and Go but he stated that these tests were considered neurological tests and he didn't use them. He did not used any self-report questionnaires. Gaspar had heard of classification predictor variables but he didn't use them.

In the United States, physicians delegate reponsibility to physical therapists for performing an evaluation and demonstrating medical necessity, based on objective tests and measures (mentioned above).

Lola, another hospital PT, said she had heard that US physical therapists were professionally 'more advanced' than Spanish physical therapists. Lola stated...

"Me encanta el calor y masaje para el tratamiento de mis pacientes"
(I love heat and massage for treating my patients)

Lola did her notes on computer but she said they were very brief narratives and did not use any of the aforementioned self-report, performance-level or classification measures.

Take Home Message

Gaspar lives well, seems to enjoy his work and has operated for the eleven years I have known him as a private practice physical therapist in a country that ensures basic health coverage to 100% of it's people.

Furthermore, physical therapists in Spain have managed to avoid the encumbrance of clinical documentation that American physical therapists put up with. They have adopted computers.

In some respects (decision making), Spanish physical therapists don't seem as far along the journey to clinical autonomy as American physical therapists. Their decision-making is still the in domain of the physician.

In other respects (direct access), Spanish physical therapists live in a more enlightened world.

It seems that wine and chocolate are reserved for those who pay for them and some Spaniards, obviously, want to pay. The exciting aspect of my trip was the finding that some Spaniards will also pay for their physical therapy out-of-pocket. Enough Spaniards pay for PT so that small, private practice physical therapists can survive, even thrive, in a 100% universal health care country.

Now, will Americans pay for PT?