"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, November 1, 2010

Frequently Asked Questions about Treatment Based Classification (TBC)

Can I substitute mobilization for thrust manipulation?


High-velocity “thrust” movement has been shown to be an important component of the treatment in the lumbar manipulation decision rule. Treatment with lumbar mobilization was shown NOT to result in better outcomes (Hancock et al).

The same logic applies to manipulation for anterior knee pain although that rule is still in the derivation stage.

No direct comparison of mobilization vs. manipulation has been performed for thoracic manipulation. The thoracic manipulation rule has been subjected to a broad validation study that showed improved functional outcomes in the manipulation + exercise group over the exercise-only group.

Further, the thoracic manipulation rule was NOT shown to predict response to treatment better than subjects manipulated without the rule.

Therefore, the authors concluded that ALL patients with neck pain without red flags for pathology should be manipulated.

Are TBC groups mutually exclusive?

That is, are all members of the lumbar manipulation group also NOT in the lumbar stabilization group? Conceptually, exclusivity is important in designing treatment groups for study. However, clinical reality belies this notion.

Manipulation and stabilization appear to be non-compatible, even contradictory, approaches to an episode of spinal care. Anecdotal reports affirm that many patients, once managed acutely with manipulation, qualify for stabilization training in the long run.

Zimny acknowledges that strict categories actually lower the percentage of patients who can be classified at all.

Are TBC groups exhaustive?

Have researchers identified all possible patient groups?

There is an uncertain benefit in trying to classify EVERY possible group when the cost and effort of rule development outweigh the possible benefits.

Hart discusses the possibility of a prediction rule that might imply the necessity for modality use in a small, well-defined cohort of patients.

Childs describes “general conditioning” as perhaps the largest cohort of patients that would benefit from physical therapy intervention. With education and possibly amended state licensing laws a rule defining this group could be applied to pre-symptomatic patients for screening and risk assessment.

What conditions are appropriate for Treatment Based Classification (TBC)?

High-volume conditions with vague indications for treatment (eg: LBP) or no consensus on treatment (eg: neck pain) are candidates for the full, four levels of rule development.

Conditions for which there is general consensus on treatment (eg: ankle sprain) may not be appropriate for full-scale rule development.

Is TBC “cookbook” medicine?

To professionals trained in a culture of naturalistic and intuitive decision making an algorithmic approach where treatment decisions are supported by “likelihood ratios” may initially seem threatening.

But, TBC algorithms can be used initially for the “heavy lifting” in developing the Plan of Care with Frequency, Duration and Expected Outcome boilerplate outputs that allow physical therapists to concentrate their time and attention on face-to-face interaction with the patient rather than tedious, narrative notes.

Expert decision makers in many disparate fields use naturalistic decision making for their common tasks.

Likewise expert decision makers also use sophisticated tools, like TBC algorithms and decision rules, that speed up complex jobs.
“A tool is a trick I use twice.” – George Polya
McGee notes that the need to establish accurate pre-test probabilities, used extensively in epidemiologic testing, requires knowing many patient characteristics in far greater detail than is possible without sophisticated data collection tools and analysis.

Finally, the father of SOAP notes decries memory-based systems in medicine that hold doctors and physical therapists accountable for perfect recall and processing of medical information:
“We use probabilities in decision making in direct proportion to our ignorance…of the situation.” - Lawrence Weed, MD
How can TBC improve Medicare compliance?
  1. TBC decision rules provide an evidence-based plan of care (frequency, duration and expected outcome) within the first 15 minutes of the evaluation.
  2. TBC allows physical therapists to concentrate on the value exchange - the face-to-face interaction that typifies a physical therapist interaction.
  3. When you are in your office, reading a chart, writing a note or pecking at your computer you are NOT giving value to the patient.
  4. TBC can establish medical necessity for physical therapy.
  5. Since most TBC decision rules use self-report questionnaires as outcome measures they can create a culture of outcomes measurement in your physical therapist workforce.
  6. TBC requires a probabilistic mindset – a way of thinking that accounts for risk factors, baseline factors and outcomes that will come to define skilled physical therapy decision making.
  7. TBC is a tool that creates autonomy in your physical therapist workforce. When you can describe your patient characteristics that predict outcome better than the referring physician can describe you become a resource for that physician.

1 comment:

  1. Thrust manipulation has been shown superior to non-thrust mobilization in the thoracic spine. Also, a recent paper comparing two lumbar manipulations to mobilization.




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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.

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