'Fancy Theory' in Physical Therapy

Outpatient physical therapists don't often deal with life and death issues.

We may help patients with...

• back and neck pain
  
• walking difficulty
  
• stiffness
  
• sports injuries
  
• balance problems

...to name a few.

We make decisions, however, that affect patients' quality of life based on their self-reported activity limitations and their performance on standardized tests and measures.

That's why I was surprised day-before-yesterday (March 5th) when I gave a presentation to a class of Physical Therapist Assistant students and I mentioned the International Classification of Functioning (ICF).

I described the ICF disablement model as THE most important decision-making tool in my practice.



I got some blank stares.

I have heard other, experienced physical therapists describe disablement models as "too theoretical" for day-to-day decision-making.

Physical therapists' decisions are often made independent of the physicians' diagnosis and may not immediately impact a patients' pain.

This is where the ICF helps me.

Diagnosis and Prognosis

The physician may send the patient with a request for ultrasound (a technique).

The patient may show up in my office expecting a massage.

I may examine the patient and find the underlying cause of her dysfunction and decide that ultrasound and massage are irrelevant to the patient's long term goals.

For example, I examined a marathon runner this week with left lumbar and hip pain at rest and right knee pain while running. Previous treatments had focused palliative modalities on the left hip region. My examination found a stiff right hip (non-painful) and lumbar hypermobility.

I treated the right hip, explained to her why right knee ultrasound and lumbar massage would not be expected to help and asked her to return Friday.

She was quite a bit better and is running a 5k on Saturday.

My physical therapist assistant students listened intently to my story and jotted down the reference for review of the ICF.

Is it just me?

I came upon disablement models later in my career (2001) and I am still impressed with their elegance.

They have simplified my day-to-day decision-making and clarified my treatments.

My mission is to train PTs and PTAs to explicitly use the ICF to make decisions.

It's not just another fancy theory.

Hopefully new grads and students, with training that I never had, will segue into their careers using disablement models as a matter of course to improve patients quality of life.

It's not life or death but the ICF does make a difference.

Get 'Bulletproof' Physcial Therapist Decisions

Get a blueprint for Bulletproof Decision Making courtesy of the Orthopedic Section of the American Physical Therapy Association (APTA).

Full disclosure: Bulletproof Decision Making is an independent project and is not endorsed by the APTA or the Orthopedic Section.

One of the 'Brand Personalities' from APTA's new Move Forward branding campaign is...

"Completing flawless and thorough documentation to insurance companies"

How do we do that?

One way to get 'flawless and thorough documentation' is the new Hip Pain and Osteoarthritis Clinical Practice Guideline from the Orthopedic Section of the APTA.

This practice guideline is special in that it is the first guideline to include measures of Activity Limitations and Participation Restrictions.

So what?

Patients can 'self report' their activity limitations using a scale such as the OPTIMAL (eg: squatting).

The new hip guideline includes measures (eg: Functional Squat Test) that objectively measure these self-reported activity limitations.

The first two guidelines (heel pain and neck pain) do not include standardized activity and participation measures.

Some Medicare experts deride patient self-report scales (like the OPTIMAL).

They say the OPTIMAL is not objective.

I think it is.

Here is evidence that OPTIMAL is objective.

If you base your Medicare compliance program on the OPTIMAL (like I do) then you may want to prepare yourself.

The new hip guidelines give you better data about patient function and are consistent with the philosophy of Bulletproof Decisions.

I can't think of a better definition for Bulletproof than "flawless and thorough".

Can you?

Can physical therapists diagnose depression?

Mary began crying in physical therapy the other day.

Tears streamed down her face as she told me the story of her automobile accident and her subsequent attempts at recovery.

She told me how difficult work and school had become - sitting and studying were too painful with whiplash and headaches.

Sleep was interrupted by pain and she got up every morning not rested, with dark, red circles under her eyes.

"I just can't go on like this", she said.

Physical therapists treat chronic pain patients whose somatic symptoms may contain an emotional component.

Physical therapists can consider the whole person when we assess the patient and we can screen for depression by asking two questions:

1. "During the past month, have you often been bothered by feeling down, depressed or hopeless?"


2. "During the past month, have you often been bothered by little interest or pleasure in doing things?"
   

These questions are taken from the Primary Care Evaluation of Mental Disorders Procedure (PRIME-MD) and are referenced in Physical Therapy Journal (December 2004 Haggman et al).

In The Cultural Context of Depression by Robert J. Hedaya, MD asserts:

"...depression is rapidly becoming the second leading cause of disability in the world."

Physical therapists treat disability using, primarily, physical interventions (eg: exercise, manual therapy, modalities, etc.).

If we try to treat problems that are emotional with physical interventions we risk making the conclusion that our interventions are ineffective.

It may be appropriate to refer our patient to a professional with training and credentials to treat depression if our screening tests are positive.

Mary answered yes to both of my evidence-based screening questions. I called her primary care physician who arranged for a referral to a physician specializing in depression.

Mary is continuing physical therapy with concurrent management of her depressive symptoms.

Does depression affect physical therapy outcomes?

I've not seen the literature that quantifies the effect of depression on physical therapy outcomes but the prudent clinician should bear the depressive diagnosis in mind when designing a restorative plan of care.

Physical therapists can diagnose the link between depression and Mary's activities:

• sitting
  
• studying
  
• sleeping

...by using a decision-making framework like the International Classification of Function (ICF) disablement model.

	ICF descriptor	ICF code
Body Functions
	Pain in Head and Neck	b28010
	Regulation of Emotion	b1521
	Psychomotor control (agitation)	b1470
Activities & Participation
	Maintaining a lying position	d4150
	Maintaining a sitting position	d4159

By studying the outcome of Mary's therapy health policy-makers will understand the impact of depression on physical therapy outcomes overall.

Adding depression to 'risk adjusted' outcome models prevents the mistaken belief that physical therapy treatments are ineffective for patients like Mary.

Adding depression to the model assumes physical therapists can assess the condition initially.

I think we can.

It all begins with your diagnosis.

I answered a question today on the Yahoo Groups PT Manager list-serve.

Hello Group,

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.

New Grad

******************

Dear New Grad,

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 health care market.

Tim

Physical therapists: Put your diagnosis in your goal

This extra step in your clinical thought process can dramatically improve your notes and charts for your Medicare compliance program.

The simple act of linking the measured impairment to the patients' activity limitation is one of the essential skilled components of physical therapist practice.

For example:

“Improve sidelying hip external rotation from 15cm to 25cm in order to improve OPTIMAL Balance from 4/5 to 2/5.”

Your clinical rationale is explicit in the goal – without the need for additional statements clarifying the link between measured impairments (hip external rotation) and patient activity limitations (balance).

Your physical therapy diagnosis may change from body part to body part and from activity to activity.

For example, the same patient may have the following goal:

“Improve AROM ankle dorsiflexion from 0 degrees to 10 degrees in order to improve OPTIMAL Stairclimbing from 4/5 to 2/5.”

Diagnosis differences

The interesting thing is that our diagnosis is not predicated on any medical model.

In the examples above, the written reason for patient referral was the following:

‘lumbar strain’ – ICD-9 code 722.93 (Other and unspecified disc disorder, lumbar region).

The physical therapist independently identified the two above mentioned areas above that needed attention that could not be consistently predicted by the medical diagnosis.

The ICF model, on the other hand, more accurately identifies the work and the decisions made by the physical therapist.

A physical therapist might diagnose, using these ICF codes, the activity limitations and impairments in body structure and function.

ICF Domain	ICF descriptor	ICF code
Activity	Walking on different surfaces	d4502
Body structure	Muscles of ankle and foot	s75022
Body function	Mobility of a single joint	b7100

Using a disablement model as the decision-making framework and making the commitment to always diagnose every patient the physical therapist is freed from the subservient, technical position in the medical model.

The physical therapist is put in the position of making decisions that are in the best interests of the patient, based on the finding from the physical therapy evaluation.

No other professionals are examining patients at this level:

• not physicians
  
• not chiropractors
  
• not massage therapists
  
• not athletic trainers.
  

Decision-making and the physical therapists’ diagnosis are the sustainable competitive advantage of physical therapy over all of these other professions in the care and rehabilitation of our patients.

Put your diagnosis in your goals to improve your written work.

Can Physical Therapists Treat Pain?

When I attended the University of Florida one of my physical therapy professors gave me this advice:

“Treating pain is a moral decision that may not be your primary therapeutic focus – treat function, not pain.”

At the time I wondered what my professor meant – treating physical dysfunction as the cause of pain in a way that alleviated the pain itself. This was a technique that eluded me for several more years.

I graduated from my university in 1992 without the benefit of learning the International Classification of Impairment, Disability and Handicap model (ICIDH) from the World Health Organization (WHO) for decision-making.

The ICIDH was first published in 1980 but it was intended for coding and manipulating data (eg: treatment codes), not for treatment decisions.

In 2001, WHO updated the ICIDH framework and re-named it the International Classification of Functioning, Disability and Health (ICF).

In June 2008, the American Physical Therapy Association (APTA) endorsed the ICF model.

“The model acknowledges that every human being can experience some level of "disability" and views functioning and disability as an interaction between health, the environment, personal and social factors.”

The new ICF framework, in my opinion and the opinion of others, greatly improves physical therapists’ ability to make treatment-planning decisions in the clinical setting.

“In clinical settings ICF is used for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement.”

Making correct decisions as to the choice of treatment intervention at the initial evaluation will speed the acquisition of good patient handling skills and, ultimately, the collection of good data.

The evidence for function

Physical therapists consistently demonstrate an ability to improve function, reduce costs and healthcare utilization and generate satisfied patients. Physical therapists achieve these outcomes by focusing treatments on measured functional deficits.

Note: The references are available in the Bibliography at www.BulletproofPT.com.

Jewell DV and Riddle DL examined 1,804 patients diagnosed with sciatica and their response to physical therapy. Twenty-six (26%) of the patients (n=473) had a meaningful response on a follow-up questionnaire.

Patients who received joint mobility interventions and exercise were more likely to improve on the follow-up questionnaire than patients who received ‘spasm reduction’ interventions. Spasm reduction interventions included ultrasound, electric stimulation, heat and ice.

Another study, this one by Deyle GA et al reported on two groups of patients with knee osteoarthritis – one group received ‘manual physical therapy and exercise’ while the other group received de-tuned ultrasound. Eight weeks later, the treatment group receiving manual physical therapy and exercise improved 55.8% on the outcome questionnaire and 13.1% in distance in a six-minute walk. The control group that received de-tuned ultrasound showed no improvement.

A follow-up study by Deyle GA et al showed the effectiveness of skilled physical therapy over a home exercise program in 134 patients. By eight weeks the clinic treatment group had improved 52% while the home exercise group improved only 26%.

Subjects in the clinic exercise group were less likely to be taking their medications and were more satisfied with the results of their rehabilitation.

Finally, Fritz et al showed in a sample of 471 patients with acute low back pain that ‘adherence to the recommendation for active care’ decreased physical therapy visits, lowered physical therapy charges and led to greater improvements in pain and disability. A one-year follow-up showed that patients receiving ‘adherent care’ were associated with lower prescription medication usage, fewer MRI scans and fewer epidural steroid injections.

The evidence for pain

One study, cited by Medicare in its Physicans’ Quality Reporting Initiative (PQRI) Summary of Quality Measure Reporting Provision for 2009, instructed physical therapists and other eligible providers to assess pain prior to the initiation of therapy.

The Summary states the following:

“Reducing the intensity of pain by just 25% has been shown to achieve a 50% improvement in functional status”. 

Treat pain and measure function

One wise therapist helped me understand that we can do both - treat pain and measure function.

Physical therapists too often feel compelled to treat pain with modalities and throw in exercise and functional training if there is any time or dollars left over.

Pain is an impairment – an impairment that can be measured.

Pain is, however, just one impairment of many impairments that can be measured using new tools available to physical therapists.

Available tools (both free and paid) include the following:

• OPTIMAL difficulty and confidence scale (free)

• AM-PAC mobility and activity scale (paid)

• ICF disability framework (free)

• APTA Interactive Guide to Physical Therapist Practice, With Catalog of Tests and Measures (paid)

• FOTO (paid)

Futhermore, according to the ICF, pain will affect patient activities and participation differently in different people.

For a Bulletproof Chart, both pain and function can and should be measured.

Treating pain by improving function and movement is one of the essential skill sets of the physical therapist.

The physical therapist, using skilled decisions and judgment, links the various measured elements using the physical therapists’ diagnosis.

Can Physical Therapists go over the PT Cap with an X-Ray?

Does an X-ray demonstrate medical necessity for physical therapy?


...or does an axial CT myelogram?


These images are examples that have in common a clear pathology that many patients and physical therapists confuse with medical necessity for physical therapy.

Right now (November 17th 2008) I have several physical therapy patients who have exceeded their $1,810 Medicare benefit and are asking me for continued physical therapy services in my outpatient clinic.

Many of these patients have chronic conditions such as the following:

• degenerative spinal stenosis
  
• massive rotator cuff tears
  
• knee osteoarthritis

These conditions show up well on sophisticated imaging scans such as X-ray, CT scans and MRI.

These conditions often require extended courses of physical therapy or multiple episodes of physical therapy in the course of a calendar year.

In my clinic, the $1,810 Medicare cap is usually reached by 16-18 visits.

It would not be unusual for degenerative spinal stenosis to take 20 visits. I'm pretty sure my experience is typical.

Who needs PT?

For an exception to the Medicare cap the physical therapist would have to show three criteria:

• Need
  
• Progress
  
• Skill

Need is often shown with physical findings.

The above X-ray and CT myelogram show physical findings based on anatomy.

Physical therapists should show physical findings based on function.

Diagnosis: Process or Label?

An epiphany in own my practice has been the use of disablement models: most recently the International Classification of Function (ICF Model) that describes the link between Body Structure and Function and Activity Limitations.

The ICF classification framework is to physical therapists what the ICD-9 diagnostic labels are to physicians.

Note the ICF model describes any health condition - for instance, your patient with degenerative spinal stenosis who has 'run out' of Medicare physical therapy benefits but asks you to append the -KX modifier to continue their care.

What do you do?

Do you ask the doctor for another script?

Perhaps you consider using another diagnosis from the old 'diagnosis list' from 2006.

Don't.

The Therapy Cap

The purpose of the therapy cap is to cut costs without limiting patient access to necessary care.

There is a large POPTs in my town that automatically cuts off therapy to every patient approaching the $1,810 Medicare Cap - regardless of need or progress.

They perceive that, as a POPTs, they are in the Medicare audit crosshairs and they refuse to add 'risk' to their caseload by appending the -KX modifier.

They are limiting care to their patients.

The Caps Work

Data for this table comes from the Outpatient Therapy Alternative Payment Study 2 (OTAPS 2) Task Order - Utilization Report.

Outpatient Physical Therapy
	2004	2006	Per cent change
Mean dollars paid per user	$864	$788.06	-8.8%
Mean dollars paid per episode	$748	$682	-8.9%
Standard deviation paid per episode	$1,047	$782	-25.4%

"The Balanced Budget Act of 1997 enacted financial limitations (therapy caps) on outpatient physical therapy (PT) and speech-language pathology (SLP) combined... In 2006 the Automatic Exceptions Process to the caps began, enacted by the Deficit Reduction Act of 2005." (OTAPS 2)

The result of the caps has been the observed decrease in per user and per episode dollars paid.

Read the full blog entry here.

Note that cost reductions occurred from 2004 to 2006.

There was no cap in 2004. The cap exceptions process began in 2006.

The Caps work - so, work with the Caps

Get better at showing need.

Show that your patients have Activity Limitations using a functional scale.

I recommend the OPTIMAL scale (free) or the AM-PAC (small $$).

Show Progress.

I've designed a neat pen-and-paper graph that easily and quickly shows functional progress over 1, 2 or 3 months.

No more discharges after 20 visits whether the patient is better or not.

Now, patients come back to me because they know I can 'go to bat' for them.

If they are getting better I can prove it.

Get a copy of the Functional Progress Graph here.

Make skilled decisions.

Use the ICF model to link impairments in Body Structure and Function with the measured Activity Limitations.

The link is your Physical Therapist's Diagnosis.

What do YOU need to go to bat for your patients?

Not fancy x-rays or 'alphabet soup' imaging.

Get better at describing your own skills using simple tools.

Get the free tools I've described in this post.

Also, get a free tutorial called Bulletproof PT to learn more.

Do physical therapists treat pain?

I took this table (my formatting) from Towards a Common Language for Functioning, Disability and Health to illustrate the role physical therapy plays in the ICF framework.

Note that physical therapy is an intervention at the Activity Limitation level of disability.

Most physical therapists would agree that our specific techniques are addressed towards the Impairment (strength, pain, ROM, swelling, etc.) but that our expected outcomes are at the level of the Activity Limitation.

How the ICF levels of disability are linked to three
different levels of intervention

Intervention
Prevention
Health
Condition
Medical treatment
Medical care
Medication
Health promotion
Nutrition
Immunization
Impairment
Medical treatment
Medical care
Medication
Surgery
Prevention of the
development of
further activity
limitations
Activity
Limitation
Assistive devices
Personal assistance
Rehabilitation
therapy
Preventive
rehabilitation
Prevention of the
development of
participation
restrictions
Participation
Restrictions
Accommodations
Public education
Anti-discrimination
law
Universal design
Environmental change
Employment strategies
Accessible services
Universal design
Lobbying for change

There are many ways to assess activity limitations but one of the best clinical ways to assess them is to ask your patient...

"How have you gotten better?"

Then score the patients' response on a 5-point Likert scale: 1 = no difficulty, 5 = cannot do.

Record serial measurements of their activity as you progress them through their physical therapy plan of care.

Remember, pain is an impairment level characteristic.

Physical therapy primarily treats activity limitations.

Use the ICF Core Set to diagnose lower back pain

Sooner or later physical therapists will be required by Medicare and commercial insurance companies to identify the impairments we treat by using the ICF Core Set.

Might as well start now.

Basically, you do it now when you select an ICD-9 code for your patient when you bill American Medicare.

For instance, 724.04 is lower back and leg pain due to spondylotic changes. While accurate, in many cases, this pathologic diagnosis is also not very informative for PT decision-making.

Like, what body part is stiff?

Are the hips affected?

Should I manipulate the patient's lumbar spine?

Which muscles need strengthening?

While the ICF Core Set is no substitute for clinical training, experience and a sharp mind it is a step in the right direction of getting physical therapists away from thinking about pathology and thinking about function.

Link the patients' activity limitations to their impairments in body structure and function.

Your assessment of the link is your physical therapy diagnosis.

Physical Therapy Diagnosis: Label or Process?

The new International Classification of Functioning, Disability and Health (ICF) speaks to the central decision physical therapists make in clinical practice:

What is wrong with the patient?

The ICF model seems to avoid the use of descriptors, or labels, that can be used to describe conditions related to human movement.

Fine with me.

The ICF Browser has descriptors of the following:

• Body Functions
• Body Structures
• Activity and Participation
• Environmental Factors

...that affect human movement and function.

Using ICF, I could make a diagnosis on a patient with neck pain that would look something like this...

"Patient has difficulty Bending, Sitting and Pushing (all measured by OPTIMAL scale) due to the following:

1. Stiff upper cervical sidebending (C0-C2).


2. Weak deep cervical flexors (DCF) muscles (measured by flexor muscle endurance test).


3. Decreased cervical rotation ROM, bilateral.
   

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

1. Therapeutic Exercise (97110) for endurance of DCF muscles.
2. Manual therapy (97140) for ROM, PROM, massage.
3. Neuromuscular Reeducation (97112) to distinguish cervical sidebending from cervical rotation.
4. Therapeutic Activities (97530) for Pushing with a stabilized cervical spine."

The descriptors used in ICF all have to do with measured findings.

The descriptors for the above diagnosis are the following:

Body Function:

• Mobility of several joints (b7101)
• Endurance of isolated muscles (b7400)

Body Structure

• Ligaments and Fasciae of the Head and Neck (s7105)

Activities

• Bending (d4105)
• Sitting (d4103)
• Pushing (d4451)

Without inventing a nomenclature or supposing the existence of any mechanism or model the physical therapist is able to accurately identify the structure at fault, the proposed treatment and the effect on the patient.

I make this diagnosis about 5-6 times per week.

Most of my patients (60%) are Medicare beneficiaries with typical, routine presentations that require a typical, routine evaluation.

I don't try to 're-invent the wheel' for each new patient I see.

I do take measurements for each descriptor listed above.

I should be able to describe to anybody the patients I treat, the intervention I use and the outcomes I expect.

'Anybody' includes the following...

• the patient
• the physician
• my physical therapist and physical therapist assistant peers
• third party payers
• federal policymakers
• national and international health researchers
• rehabilitation professionals from related professions
• the man on the street (?)

If you still want to use physical therapy diagnostic labels you will have to answer Dr. Andrew Guccione's question...

"What concepts are necessary to structure clinical observations into a recognizable pattern that also suggests physical therapy intervention?"

Generally, I recommend the ICF model to any physical therapist who wants to do a good job of treating function.

Specifically, I recommend the ICF model to any private practice physical therapist who wants to generate Bulletproof Physical Therapy Notes and Charts for Medicare compliance purposes.

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.

The Functional Classification of Neck Pain

Orthopedic physical therapists need to read this clinical practice guideline from the September 2008 issue of JOSPT.

In addition to using the International Classification of Functioning as the basis for clinical physical therapy decision-making the authors describe, in one place, many of the the tests and measures used to assess cervical impairments.

Especially useful is Table 4 which links subjective and evaluation data to interventions used during treatment.

Not only is Table 4 useful for clinical decision-making but could also be used to support 2 of the 3 criteria for Bulletproof Physical Therapy Charts and Notes

1. Medical Necessity for Physical Therapy
2. Skilled Physical Therapy (decision-making)

Written measurements of impairments are 'evidence' for a staff physical therapist to argue their case in the event of an unfavorable Medicare audit.

I recommend using high-quality, evidence-based guidelines such as this one to support not only excellent clinical decisions but also to support your Medicare compliance program.

For more information go to BulletproofPT.com.

Informed Physical Therapists Diagnose using the ICF

Informed physical therapists can make a break with 'old school' models and advance the discussion of physical therapy diagnosis by taking a look at these new APTA resources for the new International Classification of Functioning.

'Old School' models, many of which I have used, include most of the mechanistic models we learned in PT school and at 'Hilton University' (some of you may have gone to 'Marriott U' or 'Holiday Inn U').

To name a few...

NDT
PNF
McKenzie
Maitland
Mulligan
Paris
The Facet Joint
The Disc (...is a jelly doughnut)
Sacroiliac joint
McConnell taping

Now, with ICF, you can abandon models and just treat the patient.

This new paradigm (new to me since 2001) allows the physical therapist to measure characteristics of the patient that may impact function and apply treatments without regard to the mechanism.

Ah, freedom.

Freedom from justifying my treatments to other PTs, PTA's, patients or payers. If I get my patient better - who cares how I did it or what technique I used?

The power in the ICF model is that I can find freedom while a different PT or PTA can find meaning in a different way.

The ICF is a framework - not a blueprint.

I practice orthopedic PT but the ICF is equally appropriate for neuro PTs.

Use my templates and watch my videos to see how I use the ICF to inform PT orthopedic decision-making.

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.

Physical Therapy is not a 'Loss Leader'!

Some physical therapists think that refusing to accept 'loss leader' patients from Medicare Advantage plans will preserve physical therapists' pricing power.

A loss leader (in retail) is a product that is priced less than it's cost to produce. For example, Office Depot might advertise reams of copy paper at $30.99 for a case for a catalog order but the Office Depot web site has that same case for $44.99.

Office Depot will take an up-front loss in order to get you to use their catalog. They are counting on higher order volume (more items) with each catalog order.

The catalog represents a fixed-cost investment that Office Depot must amortize through higher order volume. The Office Depot web site is a relatively low-cost distribution channel that can be profitable on lower sales volumes.

What has this example got to do with physical therapy private practices?

Physical therapy private practices are fixed-cost investments for their owners. The owners only get paid back on these investments when revenues exceed costs.

Once your fixed costs (such as rent, salaries and utilities) are met you must still pay variable costs.

The variable cost to treat the Medicare Advantage patient is the cost of the ultrasound jelly you smoosh on her neck.

That's not very much.

Medicare Advantage rates are (still) higher than the one smoosh of ultrasound jelly.

You make more money than you lose when your reimbursement rates exceed your variable costs of keeping your doors open.

Cash is King

Physical therapy practice owners with full-time employees realize that pay day comes every two weeks whether or not cash is in the bank or not.

High-volume Medicare Advantage patients on your caseload prevents your employee physical therapists from sitting idle.

Yes, Medicare Advantage pays less than Medicare.

Yes, you will lower your profit margin (but you will survive).

Yes, you may ask your physical therapist employees to see more than one patient per hour.

No, you may not use aides to treat your patients (any patients - not just Medicare patients).

How, you may ask, should a struggling PT private practice owner survive?

My recommendation...?

Find out why your patient hurts.

Make the physical therapy diagnosis.

Treat the cause of their pain.

Treat the actual change in 'body structure and function' that has lead to their painful, dysfunctional state.

Tell them why they hurt and why they can't lift things up and why they can't walk more than a city block.

You must have the skills and the ability to measure deviations from normal that qualify your patient for physical therapy.

The growth in physical therapy over the last 30 years is a real trend that reflects real demand.

The value of physical therapy is undeniable.

The cost of physical therapy, however, is climbing and is subject to policy and political whims.

Physical therapy will not go away with changes in Medicare reimbursement rates.

Your physical therapy practice may go away, though.

Change is inevitable.

What will you do to create the future for you, your patients and your country?

To learn how to measure, diagnose and treat your patients better get this free tutorial.

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.