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...

• classification
• clinical prediction rules
• outcomes scales
• disablement models
• computer adaptive testing
• alternative payment systems

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?

The Episode of Care that Cost More

Miss Edy still can't kneel down.

She told me today in physical therapy.

Miss Edy has been a physical therapy patient before for short courses of PT that have, thus far, ended with a surgical procedure.

She has, at various times, received therapy for her right hip, knee, low back and neck.

In that time span, she has had her right hip replaced and has had rods-and-screws implanted in her spine.

Her complaint was always right knee pain and an inability to kneel.

She never had hip pain.

She never had back pain.

She can kneel on her left.

Pathology Persuades

Miss Edy is convinced that her surgeons did a great job on her hip and back but she is perplexed why she cannot kneel on her right.

Kneeling is a skill.

Kneeling can be taught.

Physical therapists often need to ask their patients , specifically,

"Can you kneel?"

The OPTIMAL scale specifically asks patients, "Can you kneel?".

Did Physical Therapy Fail Miss Edy?

Why did each of Miss Edy's courses of PT end in surgery?

Did the surgeons, armed with her impressive MRIs, push the surgical option too hard?

In our fee-for-service system, they had every incentive to do so.

Did Miss Edy have too much faith in technology?

Did she have low self-efficacy?

In Search of a Better Model

I have taught students and new graduates the importance making decisions by the rehabilitative model instead of the medical model.

Sometimes I get blank looks.

Sometimes I get rolling eyes.

Sometimes I get "Tim, it's just too theoretical for daily decision-making!"

But, when I still hear physical therapists saying "We need to put a little ultrasound on your shoulder for the tendinitis", I know they have abdicated their diagnostic decision-making in favor of the physician's diagnosis.


Patients hear enough of that - they need to hear a unified message of hope from physical therapists.

"You can do it!"

An Epiphany

I was never taught a disablement model. I graduated from PT school in 1992 and I learned about Nagi in 2001 when the Guide to Physical Therapist Practice was delivered to my doorstep like an extra phone book.

I dutifully read it.

I learned about Nagi's framework which has since segued into the ICF framework seen above.

How do PT decisions relate to Miss Edy and the cost of her episode of care?

I wonder if the entire episode were managed with her chief complaint in mind?

"I can't kneel down."

How much would it cost?

Would she have been saved from two major surgeries?

This image shows the payment model that distinguishes between our current system and some alternatives:

• fee-for-service (yellow)
  
• episode of care
  
• Condition-specific capitation (aka: risk-adjusted global fees)

Get the Report here and view some physical therapists discussing the alternatives here.

$100,000 dollars later, Miss Edy still can't kneel down - but now we're working on it.

Medicare Compliance through Physical Therapist Competence

I got feedback on a post today on the Yahoo Groups PT Manager list-serve.

I thought the post might be worth re-posting.
(note: this is not original content - I wrote the answer 6 hours ago for another site).

QUESTION:

I am looking for any information or suggestions on Treatment
Diagnoses vs. Medical Diagnoses.

I am having difficulty finding many good treatment diagnoses for my patients who do not have obvious gait abnormalities or radicular weakness secondary to their conditions.

Because our population is mostly spine we tend to end up with more medically based diagnoses such as disc herniation or sciatica.

I would appreciate any feedback or suggestions on this.

XXXXXXX, PT

ANSWER:

Dear XXXXXXX,

We also treat a lot (~50%) spine and we get lots of anatomic (medical)
diagnoses (eg: SI strain, HNP, sciatica).

A few years ago we started mandating a physical therapists' diagnosis
for every patient.

Now, we are able to do the following:

- improve treatment selection
- improve goal-setting
- demonstrate medical necessity
- show progress
- show skilled decision-making

...using a baseline activity scale (OPTIMAL) and a disablement model
(ICF).

We started studying these issues for our Medicare compliance program
and then we noticed patients were getting better quicker.

We use a problem list, not a diagnostic label.

I'll use 'shoulder bursitis' as an example.

We would diagnose "Difficulty Lifting & Carrying due to the following:

- weak shoulder external rotator muscle
- weak shoulder flexor muscle
- stiff shoulder flexion ROM
- stiff trunk sidebending ROM

...to be treated with the following...

- Ther Ex (97110) to strengthen shoulder flexors and external rotator
muscles.
- Manual Therapy (97140) to improve ROM of shoulder flexion and trunk
SB.
- Neuro Re-ed (97112) to distinguish shoulder rotation from trunk
rotation.
- Ther Acts (97530) for Lifting without scapular elevation.

Goals:

1) Improve shldr. ER from X to Y to improve Lifting from 4/5 to 3/5.
2) Improve shldr. flexion from X to Y to improve Lifting.
3) Improve trunk SB from X to Y to improve Carrying from 4/5 to 3/5."

(Note: OPTIMAL estimated MCID = 1.0)

In my state (Florida) my carrier (FCSO) does not use
diagnostic 'crosswalks' and I've not had denials based on using the
physician's diagnosis.

We'll have ICD-10 before physical therapists get to bill using the
ICF code set so I'm not even sure the diagnosis on the claim form
matters.

Physicians appreciate the problem list because they don't check this
stuff - no one else does either.

Linking Activity Limitations to Impairments is the physical
therapists' diagnosis.

Physical therapy diagnosis is a sustainable competitive advantage in
the care market.

Tim Richardson, PT
www.BulletproofPT.com
'Compliance through Competence'

When is a physical therapy diagnosis not a physical therapy diagnosis?

The most recent issue of The Orthopaedic Section's Physical Therapy Practice contains Developing a Physical Therapy Diagnosis for a Patient with Upper-extremity Paresthesia: A Resident's Case Problem by Trevor Lentz, Marty Huegel and Mark Bishop.

The authors state...

"the most likely source of the symptoms was cervical radiculopathy".

The problem is this 'physical therapy diagnosis' of cervical radiculopathy is that it is a medical diagnosis.

Medical doctors can get a little upset when they hear about physical therapists making medical diagnoses.

We can do better.

Instead, why not a functional diagnosis? Why not a physical therapy diagnosis that conforms to the International Classification of Functioning, Disability and Health (ICF) framework?

Using the ICF framework, measure activity limitations and impairments in body structure and function. Link activity limitations to impairments with the physical therapy diagnosis.

According to the article, the patient's symptoms "were limiting his sleep and work tolerance". These are the self-reported activity limitations.

The measured impairments included the following:

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

.
Why not a physical therapy diagnosis that simply states that the activity limitations were caused by the measured impairments?

"Limited sleep and work tolerance caused by

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test
• positive Upper Limb Tension Tests (A&B)
• limited cervical rotation bilateral

."

Why do we need a label?

The APTA House of Delegates policy statement on physical therapist diagnosis states...

"The purpose of the diagnosis is to guide the physical therapist in determining the most appropriate intervention strategy for each patient/client."

Especially, why do we need a medical label that does not inform decision-making for physical therapists?

Ivory Tower Statistics

Here's the part where I'll get myself into trouble.

The authors diagnosed this patient based on a larger positive change in post-test probability for cervical radiculopathy than for carpal tunnel syndrome or thoracic outlet syndrome.

Yet when I read the 'exercise flow sheet' I find no treatments that would apply to a 'diagnosis' of cervical radiculopathy that might not also apply to a 'diagnosis' of Thoracic Outlet Syndrome.

So, what's the point?

Why encourage physical therapists to learn and study powerful statistics (likelihood ratios and nomograms) that don't direct daily clinical decision-making?

Use the list of findings to inform the decision-making process of what to include in the plan of care.

Assuming I measured the same impairments on the same patient couldn't I take the list of findings and design a plan of care that lead to the same exercise flow sheet?

• asymmetric grip strength
• sensory loss in the C6 dermatome
• positive Neck Distraction Test - Manual Cervical Distraction
• positive Upper Limb Tension Tests (A&B)- Cervical Stretches
• limited cervical rotation bilateral - AROM

There, I didn't have to use any statistics to make a similar plan of care from the same list of findings.

Instead of making Physical Therapy Diagnosis more complicated, let's make it easier.

Unfortunately, the aforementioned HOD policy statement does not encourage improving the process. Instead, it sticks with outdated labels...

"In performing the diagnostic process, physical therapists may need to obtain additional information (including diagnostic labels) from other health professionals."

Emphasize the process, not the label.

Disability does not need a medical diagnosis label.

Disability defies labels because people are more complicated, and more interesting, than pathology.

Physical therapists should not take 'ownership' of physical therapy diagnosis

Physical Therapy Diagnosis is a blog I have posted to since about August 2007. Physical therapy diagnosis is also a topic I have been interested in since about 2005.

I first discovered PT diagnosis in reading the Guide to Physical Therapist Practice (2nd ed.).

The Guide had a reference to the Disablement Model by Nagi. Since then, Nagi's model has been updated by the International Classification of Functioning, Disability and Health (ICF) model which, among other things, replaces Nagi’s ‘functional limitations’ with ‘activity limitations’

The model describes how physical therapists can intervene by identifying the connection between measured activity limitations and measured limitations in body structure and function (Nagi's 'impairments').

Physical therapists identify the link and that process is the physical therapy diagnosis.

I can only say that I wish I had learned the disablement model in my undergraduate education. To say that my physical therapy practice patterns have evolved since adopting theis framework would be an understatement.

Not evolution, but revolution.

Imagine my surprise to learn that 'Physical Therapy Diagnosis' is a term not recommended for physical therapists by none other than the foremost author on functional assessment in physical therapy...

...Alan Jette, PT.

I found his 1989 article Diagnosis and Classification by Physical Therapists: A Special Communication in which he briefly discusses his thoughts on the matter...

"There are pitfalls along the way into which physical therapists might easily fall. One that particularly concerns me is the use of the phrase 'physical therapy diagnosis.' I concur with Sahrmann, who recommends that the term "diagnosis" be used by the physical therapist in referring to the identified condition that is the focus of the physical therapist's treatment. It should not be used to reflect ownership of the condition, which would be the inevitable consequence of using the phrase 'physical therapy diagnosis.'"

(Jette, 968-969)
I don't know how much has changed in the last 19 years...

Are we in danger of alienating ourselves from physicians if we persist in using the term 'physical therapy diagnosis'?

Has there been a surge in professional diagnoses?

• nursing diagnosis
• chiropractors diagnosis
• personal trainers diagnosis

It may be too late for me.

I've already taken a position on this issue. It's changed my life and my practice.

What about you?

Physical Therapist uses the ICF model for Decision-Making

This is the first physical therapy article (that I have seen) since the APTA adopted the International Classification of Functioning (ICF) framework in June 2008 that uses the framework for decision-making.

I've used the framework when it was called the International Classification of Disability, Impairments and Handicaps (ICDIH) since late 2007, when I started writing this blog on Physical Therapy Diagnosis.

I've found the process liberating.

I feel more able to help my patients and at the same time I feel less personal responsibility if those patients fail to improve with physical therapy.

I just take the measurements (impairments and abilities).

I find the link - the Physical Therapy Diagnosis.

The treatments are more or less routine.

Back to the article...

This case report by Kevin Helgeson, PT, DHSc describes the treatment of a 23-year old girl with a recurrent patellar dislocation. The measurements and treatments described in the article are pretty routine: exercise, patellar gides, proprioceptive training, etc.

What I found interesting, in the 'Discussion' was the authors' comments on their decision-making process.

"An important aspect of this evaluation process in the ability to reevaluate the interrelationships within the ICF framework and decisions made throughout the course of treatment. The choice of impaired patellofemoral joint stability as the primary impairment for the patient in this case report was re-evaluated through an assessment of the level of improvement of the patient's primary activity limitation. If she had not been making progress toward resolving the activity limitation in the first weeks of treatment, then reevaluation of the primary and secondary impairments would have been indicated."

I can use this in my practice.

We use the OPTIMAL scale. We use the OPTIMAL to write Bulletproof PT Notes for Medicare compliance.

For example, I follow-up with a patient using the OPTIMAL.

They are not making progress with walking long distances. Their goal is 2/5 OPTIMAL. I record their current score, 4/5 (lower scores are better).

Based on their failure to improve, I decide to change their plan of care and try again.

I have just demonstrated skilled physical therapy using my decision-making. The OPTIMAL was my tool and the ICF was my framework.

You can see more examples of skilled physical therapy using the OPTIMAL (and other tests) within the ICF framework. It's all Medicare compliant. It's called Bulletproof Physical Therapy Charts and Notes.

New Physical Therapy Paradigm

There is a new game in town.

Physical therapists may have to hit the hit the books again to learn the new disability paradigm...

APTA Endorses World Health Organization International Classification of Function Model

In school (I graduated in 1992 from the University of Florida), we learned about impairments in range-of-motion and strength.

We learned about disability and how physical therapists can help people.

We learned that physical therapists link impairments to disability via the physical therapy diagnosis.

Now, the link is the same.

Physical therapists still do the same thing.

The names have changed.

The new ICF model uses new terms.

The terms are important because words direct thinking.

Words are powerful. Words are labels.

Words like Disablement = Participation.

Words like Functional Limitation = Activities.

Words like Impairment = Body Structure and Function.

The American Physical Therapy Association has gotten behind the new paradigm.

Soon, educational programs will get on board.

Then, your students and new graduate physical therapists will arrive...

...talking the new language of Participation, Activities, Body Structure and Function.

Then Medicare will get on board.

Then, you will have to get the new paradigm.

Get it now. Get the new paradigm. Because it's good for your patients.

Because it can help your clinical decision-making.

Learn how you can work this new paradigm into your clinical practice.

Get Bulletproof Physical Therapy Charts and Notes.

Get it.

APTA Endorses World Health Organization ICF Model

The American Physical Therapy Association (APTA) recently endorsed the new World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) Model.

I doubt most physicians consider disability when making a physical therapy referral.

Most medical doctors consider pathology first.

The first line intervention for pathology is usually pharmaceuticals.

Disability , and the physical impairments that lead to disability, is better addressed through physical therapy interventions such as Therapeutic Exercise (CPT 97110), Manual Therapy (CPT 97140) and other active interventions.

In the new model Impairments are replaced with 'Body Function & Structure'.

Functional Limitations are replaced with 'Activities'.

Disabilties are replaced with Participation.

Physical therapists are usually pretty familiar with the concept of disablement.

Medicare, in the United States, specifically pays physical therapists to treat disability, not pain.

The Orthopedic Section of the APTA is using the new ICF model to "Develop Evidence-Based Practice Guidelines for Treatment of Common Musculoskeletal Conditions".

The 'potential benefits of the project are to identify appropriate outcome measures'.

Currently, Medicare recommends the OPTIMAL scale for outcomes in outpatient physical therapy.

Watch OPTIMAL videos to use it for Medicare long term goal setting.

The Disablement Model

The Disablement Model

The Disablement Model is a great way for physical therapists and physical therapist students to begin thinking about physical therapy diagnosis.

My undergraduate physical therapy education at the University of Florida in 1992 did not have any mention of Nagi or WHO (World Health Organization) or the process that leads from tissue pathology to physical handicaps.

Physical therapist assistants, however, that graduate in 2008 will have had 4 semesters of information that is permeated with information on the disablement model and they should be comfortable with practice patterns that incorporate ‘disablement thinking’.

Disablement thinking was a concept in 1992 but disablement thinking should be common practice in 2008. If physical therapists are not practicing with disablement concepts firmly in mind then it is because there are not sufficient tools in place to bridge the gap between concept and practice. I have designed the SIMPLE system to be one of those tools.

The SIMPLE system is a decision-making tool for physical therapists to decide on a diagnosis, to decide on goals and to decide on physical therapy interventions.

Pathology doesn’t do a good job of guiding the decision-making process for the physical therapist (see Sandstrom RW in PT Journal).

The Nagi Model

The SIMPLE system adheres to the Nagi disablement model and to the Guide to Physical Therapist Practice regarding the relationship among disability, functional limitations and impairments.

The SIMPLE system also adheres to the recommendations in the latest updates to the Medicare Benefit Policy Manuals and in the state-specific Local Coverage Determination
(here is the link for Florida) for the purpose of creating compliant physical therapy plans of care and for physical therapy goal setting.

Begin with the physical therapy diagnosis

The diagnosis is the link between the measured impairments and the measured functional limitations. The SIMPLE system cannot make the diagnosis – only the physical therapist can make the diagnosis. The SIMPLE system automates the charting and the documentation once the physical therapist makes the diagnosis.

Physical therapists’ time is far too costly and their expertise too valuable to spend in their back office making up new goals for certain high-volume diagnoses.

Physical therapists need an easy way to put on paper the skilled stuff they do with patients. If a physical therapist doesn’t have to worry about “What do I have to write down to pass a Medicare audit?” then they can spend more time with their patient doing the skilled care that gets people better.

Skilled care is not complicated but it is hard work. Medicare documentation is complicated but it doesn’t need to be hard work. Not if you use the SIMPLE system.

It’s a simple process.

It’s a simple system.

Bottom line, it’s better physical therapy.

Tim Richardson, PT